Download Medical Marijuana And Methadone Treatment Programs Jassin M

Medical Marijuana
And
Methadone Treatment
Programs
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor
of academic medicine, and medical author. He
graduated from Ross University School of
Medicine and has completed his clinical clerkship
training in various teaching hospitals throughout
New York, including King’s County Hospital Center
and Brookdale Medical Center, among others. Dr.
Jouria has passed all USMLE medical board
exams, and has served as a test prep tutor and instructor for Kaplan. He has developed
several medical courses and curricula for a variety of educational institutions. Dr. Jouria has
also served on multiple levels in the academic field including faculty member and
Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several
continuing education organizations covering multiple basic medical sciences. He has also
developed several continuing medical education courses covering various topics in clinical
medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson
Memorial Hospital’s Department of Surgery to develop an e-module training series for
trauma patient management. Dr. Jouria is currently authoring an academic textbook on
Human Anatomy & Physiology.
Abstract
Methadone is a powerful narcotic that can be used to treat severe pain as
well as the symptoms of withdrawal from heroin. However, methadone itself
can be addictive, and the withdrawal symptoms can be severe. Medical
marijuana is now being used to ease the symptoms of methadone
withdrawal as patients are going through the detoxification process.
Although it does not alleviate all withdrawal symptoms, it makes the process
much easier on patients and medical staff alike.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 4 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Pharmacology content 0.5 hours (30 minutes).
Statement of Learning Need
Medical marijuana is used to treat several chronic conditions, including
addiction to methadone. Health professionals are often uninformed of the
underreported use of medical marijuana and trends for future research.
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Course Purpose
To provide nursing professionals with current knowledge of new laws and
evidence influencing the use of medical marijuana and methadone treatment
programs.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC
Release Date: 2/15/2016
Termination Date: 6/28/2018
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. Use of cannabis may be able to help patients who struggle with
addiction to the synthetic opioid ________________.
a. heroin
b. methadone
c. oxycodone
d. morphine
2. Methadone may be used as an analgesic medication because
a. of methadone’s use in detoxification.
b. methadone helps patients experience fewer side effects of withdrawal.
c. methadone is a powerful pain reliever.
d. methadone manages effects of withdrawal from some very strong
narcotics.
3. Some studies have determined that marijuana use may
a. cause problems with fetal brain development.
b. lower or raise blood pressure.
c. contribute to ischemic heart disease.
d. All of the above.
4. A patient who has asthma or breathing problems –
a. may take methadone but only intravenously.
b. may take methadone safely.
c. should not take methadone at all.
d. may take methadone so long as there are no other side effects.
5. The most common methadone administration is ____________.
a. pill form
b. intravenous injection
c. suppository form
d. liquid form
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Introduction
The integration of science and nature come together when prescribing
medical marijuana for a number of different health conditions and for
treatment of various uncomfortable symptoms. Marijuana is a plant that has
been grown and used for medicinal purposes for centuries, but legislation
has limited its use in the medical arena. The various forms of its use, as well
as its physical effects on the body, continue to be a treatment option
available to some patients who struggle with health issues that have not
responded to mainstream methods of treatment.
One condition in which medical marijuana has been effectively used is with
the management of opioid addiction to substances such as methadone. This
is a powerful drug that is used for pain relief as well as for managing the
effects of withdrawal from some very strong narcotics, such as heroin.
Methadone maintenance programs can successfully help patients who
struggle with opioid addiction to overcome their painful and frightening
symptoms of withdrawal and ease into a life without narcotics.
Alternatively, some patients move from their previous substance addiction to
a methadone substance use disorder, the very drug used to try to help them
overcome substance abuse. These patients then need further treatment and
guidance to also overcome their addictions and to reach a point where they
live drug-free lives. Use of cannabis may be able to help some of these
patients who struggle with methadone addiction.
The terms substance use disorder and addiction will be used interchangeably
in this learning module. Differences in terminology may vary based on
national and regional terms and classifications as published by medical and
psychological associations. The Diagnostic and Statistical Manual of Mental
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Disorders, Fifth Edition (DSM-5) did away with the terms substance
dependency and abuse and replaced them with the terms substance use
disorder and addiction. Because of the growing numbers of states that have
approved marijuana for medical use and the recent legalization in some
areas for its recreational use, it is important for healthcare providers to
understand newer legislation influencing marijuana use in their communities,
as well as the drug’s purposes, methods, and the effects of medical
marijuana, including its use as part of treatment for methadone addiction.
Medical marijuana has proven to be useful for many, but controversy still
exists about the use and regulation of this drug.
Methadone
Methadone is a narcotic analgesic that has been developed for relief of
moderate to severe pain. Its effects are similar to those of other opioid
analgesics and it most often resembles morphine in characteristics.
Methadone has M-opioid receptor agonist properties, which means that it
activates a specific type of opioid receptor in the body, the M receptor, and
makes it similar in effect to heroin or morphine.
Methadone is a synthetic drug. It was first developed during the early 20th
century by several physicians who were searching for an opioid analgesic to
administer during instances of severe pain among their patients, but they
also wanted a drug that would not be as addictive as morphine. The drug
was fully developed for use by the end of World War II and named
methadone at that time. As illicit drug use increased in the United States
during the middle of the 20th century, the use of methadone expanded to
become not only a potent analgesic, but also for use in helping those with
drug addictions to go through withdrawal.
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Today, methadone’s use is primarily centered on helping patients overcome
an opioid substance use disorder and addiction; it also provides effective
pain relief when prescribed as an analgesic. While not helpful for all patients,
prescribing providers who want to use this specific medication should
become familiar with the essential data about methadone and its
prescriptive properties, its use as part of different treatments, its potential
side effects, and its ability to cause addiction when misused by patients.
Use in Detoxification
A patient undergoing narcotic detoxification and withdrawal faces many
physical and psychological difficulties throughout the process. The symptoms
that develop during this period can be extremely uncomfortable and the
body physically craves the drug, making it very difficult to simply stop taking
it. Healthcare clinicians have discovered that transitioning from regular use
of a narcotic to a drug-free state may be less complicated by giving the
patient another drug in its place that has fewer side effects and that does
not produce as strong of a high feeling. Replacing narcotic drugs of abuse
with methadone has been shown to be effective in helping those who
struggle with a substance use problem to overcome addiction.
Methadone’s use in detoxification helps the patient with a substance use
disorder to recover from and experience fewer side effects of withdrawal
because methadone is an opioid that provides some of the same effects.
Methadone is also a powerful pain reliever, so it may help with some of the
painful symptoms that develop with withdrawal. Conversely, methadone
may also be used as an analgesic medication to combat other types of pain,
including cancer pain, neuropathic pain, and other situations that cause
chronic pain.
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Pain Relief
Although methadone use increased in popularity for the management of
narcotic addiction, it is now also increasing in use for the treatment of
moderate to severe pain, which may or may not be associated with narcotic
withdrawal. This is evidenced by the increase in sales of methadone by over
70 percent between 1999 and 2002.15 More providers have recognized the
effectiveness of using methadone outside of rehabilitation programs for
addiction treatment and have started to focus more of its purpose on pain
relief.
A patient may receive a prescription for methadone for pain relief and may
fill the prescription at any pharmacy that would fill any other type of opioid
drug; however, the patient who takes methadone for drug addiction,
including its use for pain control during drug withdrawal, must only use a
prescription from a provider who is registered with the U.S. Drug
Enforcement Agency for this reason and may only use a specific type of
pharmacy that has been approved by a regulatory agency to fill a
prescription. In other words, methadone prescriptions can be filled at any
licensed pharmacy only if the drug is being used for pain relief and not for
addiction withdrawal. This is significant, because methadone users have the
potential to abuse the drug and misuse the system by filling prescriptions for
one purpose but using the drug for another.
Because of its action as an opioid agonist, methadone can successfully treat
severe pain among some patients. Methadone has been shown to be a
serotonin reuptake inhibitor, so it may successfully manage neuropathic pain
well.15 It can be administered several times each day to control pain, but
because it has a long half-life in the body, it should not be used for
breakthrough pain, since its levels cannot be well controlled. Methadone has
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a half-life of between 15 and 60 hours in the body; when the half-life is this
long, it takes days for the plasma concentrations of methadone to reach a
steady state. For this reason, it is also not used as necessary (PRN)
medication, but instead should be given in scheduled doses.
Methadone provides a relatively powerful form of pain relief through
analgesia. According to the Drug Enforcement Administration (DEA), an 8 10 mg dose of methadone is similar in analgesic effects to a 10 mg dose of
morphine.14 As with other opioid analgesics, its pain relief lasts anywhere
from 4 - 8 hours. When it is absorbed, methadone is distributed to the
kidneys, muscles, liver, and lungs. Because it can treat moderate to severe
pain, methadone may be added to an analgesic regimen if the patient is not
otherwise responding to non-opioid medications for pain relief.
Methadone has been demonstrated to be effective as a pain reliever for a
number of different types of pain, including neuropathic pain associated with
such conditions as shingles, complex regional pain syndrome, back pain, and
headaches. Methadone could potentially be used to treat some types of
cancer pain, but it is not considered a first-line treatment because of its high
potency and difficulties with titrating it to control its levels.
It may also be utilized in situations when a patient is experiencing chronic
pain or under special circumstances, including hospice and palliative care. A
study by Salpeter, et al., in the Journal of Palliative Medicine demonstrated
that low doses of methadone, when combined with haloperidol, provided
exceptional pain relief without the need for dose titration and did not result
in opioid-induced hyperalgesia, which is an abnormally high sensitivity to
pain after chronic use of opioids. The study showed that the methadone was
successfully used in treatment of chronic pain that occurred from both
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cancerous and non-cancerous states and that it could be effectively
implemented as part of treatment with palliative care.16
Despite this and other research results that have shown methadone’s
effectiveness in managing chronic pain, the drug is not the first choice to use
when it comes to managing chronic pain states. In fact, the American
Academy of Pain Management issued a warning statement that methadone
should not be considered the first choice of pain management methods when
treating chronic pain because of the high number of deaths associated with
its use. Methadone accounts for approximately 2 percent of opioid
prescription analgesics in the U.S. but is responsible for up to one-third of
deaths related to opioid toxicity and overdose.17 Because of this, prescribing
providers must make careful considerations when preparing to prescribe and
administer methadone for chronic pain.21 Before prescribing methadone, the
provider should be familiar with the pharmacokinetics of the drug and should
weigh its risks against its benefits for the particular client. Further, the
provider should have a plan in place for monitoring the patient’s response to
the drug when it is administered and develop a response plan for managing
unexpected outcomes.
Methadone use for pain relief must be closely monitored and the patient
carefully supervised while receiving the drug. The U.S. FDA has issued a
statement that methadone use in pain control could cause respiratory
depression and cardiac compromise, which can ultimately lead to death of
the patient.14 Considering this, when administering methadone for pain
control, the healthcare provider should increase doses very slowly and
monitor the patient’s pain relief with dose titration. Only those healthcare
providers that are experienced in using methadone, including an
understanding of the drug’s pharmacology and half-life, the parameters for
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its titration and discontinuation, and knowledge of its drug interactions,
should administer methadone as a form of treatment.
In order to prescribe and administer methadone safely when giving the drug
for pain relief, the provider should start with a low dose of the drug and
increase the dosage very slowly. In fact, a common saying used among
healthcare professionals to guide prescription of methadone is to “start low
and go slow.” Those who have experience with its use and who can
recognize its adverse effects should be the only ones administering
methadone. Those without experience should undergo training or further
education about the responsibilities of administering methadone before
giving the drug to patients.
Recommendations for methadone administration are to start at no more
than 2.5 mg total of methadone every 8 hours in the beginning.18,21 When
titrating the dose of methadone among patients who have little experience
with opioid analgesics, the provider should not increase the dose more often
than at least every 5 to 7 days so as not to risk methadone toxicity. When
giving methadone to a patient who has already been taking other types of
opioids, such as morphine, the previous drug should first be stopped before
administering a dose of methadone that is equal in analgesic strength.
Despite its safety considerations when being used for pain relief, methadone
does provide benefits to patients who use it as an analgesic. Because of its
long half-life, the patient may not need as many doses of the drug to
achieve pain relief and may be comfortable with longer dosing intervals.
There are several methods of administering methadone as well, including in
liquid, tablet, intravenous, and sublingual forms. Methadone is also relatively
inexpensive when compared to some other opioid drugs; the drug itself may
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be cheaper to use but there are also cost differences if the patient uses less
methadone overall because of its extended analgesic effects.
When using methadone, the patient should be instructed to avoid drinking
alcohol or using any other kinds of drugs, as the combination of such
substances can lead to drug toxicity. Methadone is particularly dangerous
with substances that are depressants, such as alcohol, over-the-counter
sleep aids, muscle relaxants, or benzodiazepine medications, which can
suppress the respiratory system and cause difficulties breathing, changes in
level of consciousness, or respiratory failure. Because methadone can cause
drowsiness, the patient should also be taught to avoid engaging in any
activities that could be dangerous or harmful while under the influence of the
medication, such as driving a car. Methadone can affect a person’s ability to
concentrate, which could be risky in situations when the person needs to
focus on a specific task. The prescribing provider or nurse working with the
patient who takes methadone must continue to remind the patient about this
drug’s status as a narcotic and it that should be taken with care.
Withdrawal Treatment
The most well known use of methadone is its purpose in assisting some
patients who are recovering from narcotic addiction. Methadone first started
being used for narcotic withdrawal treatment during the 1960s, when illicit
drug use had dramatically increased in the U.S. During that time, healthcare
providers were seeing more and more patients with heroin addictions who
could not overcome their substance use disorder successfully and endure the
sequence of withdrawal from the drug. Methadone was given to some of
these patients as a substitution for heroin, in a process then known as
methadone maintenance, which replaces the heroin and prevents withdrawal
symptoms. In 1972, the federal government provided regulations for the
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controlled use of methadone HCl (Dolophine®) as part of treatment for
those recovering from heroin addiction.12
Methadone maintenance is the term used to describe the process of
administering methadone to a patient overcoming opioid addiction.
Methadone maintenance clinics are rehabilitation programs that work with
patients who specifically struggle with drug addiction and who are trying to
recover from a substance use disorder. Methadone is used for recovery from
certain opioid addictions, but it is not useful in recovery for all types of
substance use and addiction. The most common use of methadone in
withdrawal treatment is for heroin addiction, however, it is also used for
recovery from other drug addictions, including morphine and oxycodone. It
should be noted that methadone is not administered to act as a substitute
for heroin, as its effects differ between the two drugs. Heroin is a shortacting drug that typically requires 3 to 4 doses a day to prevent cravings
from developing in an addicted person.27 Alternatively, methadone is a longacting agent that can be used once a day to prevent heroin cravings from
developing; it is considered a treatment for heroin addiction but is not meant
to substitute for the drug.
There have been a number of studies that have shown the effectiveness of
methadone use in the treatment and management of opioid drug
withdrawal. In addition to management of withdrawal symptoms, methadone
use may also be helpful in impacting other negative outcomes of addiction
that may occur with some patients, such as with the spread of infectious
disease and decreased quality of life. A study by Demaret, et al., in the
Journal of Addiction Research and Therapy showed that heroin users with
criminal histories had decreased their level of involvement in crime and had
committed fewer crimes during a 12-month period when undergoing heroin
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addiction treatment. The study suggested that new methadone treatment
through a methadone maintenance clinic, for example, could help some
patients to decrease their criminal behavior.13 This and other studies like it
have demonstrated that treating drug addiction, such as with methadone as
a form of treatment, can improve behavior and quality of life for addicted
persons.
When compared to using other narcotic drugs of abuse such as heroin or
morphine, methadone has a much more gradual effect after administration;
in essence, the person still receives the opioid analgesic effects of
methadone but it happens at a much slower pace. Instead of feeling the
rapid high of intravenous drug use, the person who is given methadone as
part of a drug addiction treatment program will still experience some of the
effects but in a much longer timeframe. Methadone has a slow onset and its
effects are much milder when compared to some other opioid medications so
that the patient will not experience the euphoria accustomed to with opioid
drug abuse.
As an example, a patient who is receiving treatment for heroin addiction
may have been abusing the drug for some time, developing a tolerance for it
and needing it on a regular basis to avoid symptoms of withdrawal. When
the patient uses heroin, the effects of the drug develop quickly and he or she
experiences a rapid rush of euphoria. After entering treatment, if the patient
is given methadone, he or she will experience fewer symptoms of withdrawal
because a drug that is an opioid analgesic is still taken, however, he or she
will not experience the same rush accustomed to while using heroin. A
patient who develops a methadone substance use disorder during treatment
for heroin may not be addicted to it. A substance use disorder occurs with
many different types of drugs and often develops as part of the therapeutic
14
effects of the drug. The physical response that occurs with methadone use
as treatment for drug addiction differs from physical addiction to methadone.
Methadone is administered to patients experiencing symptoms of withdrawal
from opioid drugs. The dosage and frequency of methadone prescribed is
followed closely and based on how the patient responds to opioid
withdrawal. The amount of methadone administered is titrated according to
severity of cravings; continued cravings and symptoms of withdrawal require
continued administration of methadone with an initial increase in dosage to
overcome more of the severe symptoms. Alternatively, a decrease in
cravings and improving symptoms of withdrawal can signify that it is time to
decrease the amount and frequency of methadone administered. Each
patient’s response to methadone treatment can vary based on his or her
medical history and opioid tolerance.
Opiates are one of the oldest substances to cause a substance use disorder
and addiction. The original substance comes from the poppy plant, and
includes such drugs as morphine and codeine. Opioids have also developed
as synthetic forms of opiates; some types of opioids include heroin,
hydromorphone, hydrocodone, and oxycodone. Many of these drugs are
used to treat pain, but at high enough doses, they produce feelings of
euphoria, which makes them more likely to be misused. When a person
develops a substance use disorder, he or she may seek to use the drug at all
costs, despite the physical bodily harm caused. The body develops a
tolerance for the drug over time because of the changes it causes in nerve
receptors when used; after using opioids for a time, a person’s body may
require increasing amounts of the drug with each use to reach the same
effect. Additionally, after a certain amount of tolerance has developed for
15
the drug, the individual experiences withdrawal when the drug is excreted
from the body.
The process of detoxification involves stopping use of the drug and going
through a period of withdrawal, in which the body reacts to the drug missing
from its system. In most cases, detoxification is done under medically
supervised conditions because the effects of withdrawal are not only
unpleasant, they can be dangerous for the patient. The patient may
physically crave the drug and the withdrawal symptoms can be so
uncomfortable that detoxification requires patient monitoring to prevent the
patient from using more of the drug. Some common symptoms of
withdrawal include agitation, anxiety, tremor, hot flashes, nausea, vomiting,
and diarrhea.24
Methadone maintenance may be administered in an inpatient rehabilitation
facility or on an outpatient basis. Because a patient could develop an
addiction to methadone, its use is carefully controlled and may be regulated
only to those with a substance use disorder who have not responded to
other forms of substance use treatment. When administered as part of
inpatient treatment, a physician and a psychiatrist throughout the process
will most likely monitor the patient. Healthcare providers and nurses who
work at these centers are available to help patients going through symptoms
of withdrawal by providing medications and comfort measures for
symptoms, as well as administering methadone doses and monitoring for
side effects and responses to the drug.
An example of an inpatient stay at a methadone clinic would be two or more
days of daily doses of methadone for the patient recovering from opioid
addiction. The dose is closely supervised and the healthcare provider
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monitors the patient’s cravings to determine if the methadone dose is
effective. If the patient needs more time as an inpatient to receive
treatment, his or her stay may be extended. Over time, the dose of
methadone may be reduced at a calculated level that allows it to continue to
provide the effects the patient needs but at a slightly smaller dose.
The initial time of detoxification involves getting the patient through the time
of excreting the original opioid from his or her system while taking
methadone. The patient may attend counseling or group therapy after the
initial detoxification process is over. These sessions discuss the effects of
addiction and help the patient to work through other issues that may be
present while simultaneously learning how to manage emotions and
thoughts in order to eventually succeed after rehabilitation.
A patient may also undergo outpatient methadone maintenance after going
through detoxification from narcotic addiction and after reaching a
maintenance level dose of methadone. If the patient is prescribed
methadone to take on an outpatient basis as part of drug rehabilitation, a
family member or close friend may administer the drug to the patient to
better help with regulating dosages and to prevent the patient from taking
too much or otherwise misusing the drug. In some cases, the patient may
also need to return to the clinic every day to receive a dose of the drug.
Regular urine testing may also be required to check for the presence of other
drugs in the patient’s system beyond the prescribed methadone. Outpatient
programs may also require that patients attend individual or group
counseling sessions as part of being in the program and the patient may
need to document attendance at these sessions to demonstrate cooperation
and willingness to be in the program.
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Prior to discharge from the methadone clinic, the patient and significant
other or support person should learn about the process of using methadone
for management of drug withdrawal and should understand the importance
of monitoring intake of this drug. The patient and his or her family may also
need to keep track of how much of the drug is taken and the total dosages
taken over certain periods of time. This is to monitor treatment parameters
closely to ensure that the patient is not taking too much of the drug;
tracking also monitors whether anyone else in the household may be
inappropriately using methadone as well.
Some methadone maintenance clinics, whether inpatient rehabilitation
facilities or outpatient centers, offer other services for patients and families.
Clinics may have services such as individual or family counseling for ongoing
support for patients struggling with substance use and addiction. Other
services that also may be offered include vocational training and medical
care or referrals for medical services.
Contrary to popular belief, a patient who has reached a stable methadone
dose for treatment of drug addiction is typically able to function in a normal
capacity; the stable dose allows the patient to continue to perform duties at
work and attend to normal responsibilities.27 A patient who is on a stable
dose of methadone is not experiencing euphoria or withdrawal associated
with opioid effects, nor is he or she sedated and lethargic. The maintenance
dose of methadone, once reached after careful monitoring through
detoxification and rehabilitation, keeps the patient in a stable place to
function in a normal capacity.
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Delivery Methods
There are several methods in which methadone may be administered to
patients; the delivery method and dose depends on the patient’s background
and the situation in which the drug is being used. Within the treatment
setting, methadone is typically administered in either liquid or tablet form.
Methadone may also be available as subcutaneous or intravenous injection,
particularly in cases when it is used as part of palliative care. Patients who
cannot swallow tablets or liquids may have methadone formulations created
as suppositories for administration of the drug.
When used as an illicit substance, methadone is sometimes injected
intravenously, which obviously requires a syringe and needle. An individual
may inject methadone by injecting the liquid form of the medication that is
prescribed for oral use. Other intravenous users may dissolve tablets of
methadone in a small amount of liquid, draw up the amount in a syringe,
and then inject the dose intravenously. Either of these methods is extremely
dangerous and can lead to methadone toxicity, overdose, and death.
Intravenous injection of methadone is not legally approved, nor is it the
method used when utilizing methadone for treatment of addiction. Injectable
methadone, when used as an illicit drug, carries many of the same risks as
injecting other drugs, such as heroin, and the drug user is at risk of health
consequences, including infection with hepatitis B or HIV.
Liquid
The most common type of administration of methadone is in liquid form.
Liquid methadone is beneficial because pouring the right amount of the drug
can strictly control the dose; this compares with tablets, which come in one
dose per tablet and require the patient to take only the amount available
through each pill. With liquid, a patient’s dose can be adjusted up or down
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based on total milligrams and at small increments, if needed, depending on
the patient’s response to the methadone and the cravings experienced.
Liquid methadone is usually made from powder that comes from the
pharmacy dispensing the product; it is then mixed with water for dilution.
The powder may also be mixed with other liquids, such as juice, or flavoring
may be added to the water, to make it more palatable. When dispensing the
liquid preparation, the nurse shakes the bottle before use to emulsify any
powder that has separated from the liquid. Pouring the amount into a
medicine cup or drawing up the exact amount with a syringe allows it to be
dispensed in an accurate amount. The amount of the dose of the liquid form
varies between products and may be more if the liquid is in concentrated
syrup. Typical doses provided in liquid form vary between 1 mg per mL to up
to 10 mg per mL.
If a patient is using liquid methadone at home, he or she should have a
system of taking the exact amount of the liquid for each dose, such as with a
graduated medicine cup that is marked for specific doses or a syringe that
will allow the patient to draw up the exact amount. If the patient does not
have one of these items to properly measure the medicine, he or she should
ask for one from the pharmacist where the medication was received; and the
patient should not try to measure the dose using kitchen spoons or cups in
the home.
Whether or not liquid methadone is prescribed depends on the patient’s
condition and background for using the drug. Some facilities that offer
methadone maintenance only use liquid methadone because of the ability to
titrate the drug. Liquid methadone may also be more cost efficient when
compared to other methods of administration. As with any other type of
20
drug delivery method, facilities must weigh the benefits against the
disadvantages of administering methadone in liquid form or choosing
another method.
Tablets
Oral tablets of methadone can be administered to patients on an inpatient or
outpatient basis. Each dose varies slightly between patients, depending on
their medical background and whether the methadone is causing a change in
opioid cravings. The standard dose with oral tablets is between 80 and 100
mg per day, with the effects of each dose lasting approximately 24 hours.12
Because the effects of a tablet of methadone lasts for so long, the patient
requires much fewer doses overall and should theoretically take 1 to 2
tablets only once a day, instead of continuing to dose by taking oral pills
throughout the day.
A form of methadone tablet is sometimes called a disket; each disket
contains approximately 40 mg of the drug, so the patient may take 1 to 2
diskets at a time, depending on the prescribed dose. This method of
administration differs from other types of oral methadone tablets, in which
the patient swallows the tablet whole with a glass of water. The disket is
designed to be dissolved in water; upon administration, the patient places
the disket in a glass of water, allows it to dissolve, and then drinks the
solution. When dissolving one of the tablets, the patient may use water,
juice, or other non-alcoholic beverage; it must be at least 4 ounces to
dissolve the full tablet and the patient should wait until the disket has
dissolved before drinking the medication, however, in many cases, the
medication does not dissolve completely, which means that the patient may
need to add more liquid to the glass to get the entire dose of the medicine.
21
The forms of methadone that may be administered differ based on the need
for the drug. For instance, methadone tablets may be used for the
management of opioid addiction but not necessarily for pain control. As an
example, a 40 mg tablet of methadone may be a regular part of a patient’s
drug regimen when treating opioid addiction, but this dose and the
formulation are not approved by the U.S. FDA for pain management.14
Instead, the oral tablet form of methadone at this dose may only be used in
healthcare centers or rehabilitation facilities designed for the treatment of
narcotic addiction.
When taken for pain, methadone tablets are typically administered starting
between 2.5 mg and 10 mg, given every 8 hours; the starting dose for the
patient depends on whether opioids had been taken in the past, or the
patient is opioid naïve. When taken for drug withdrawal during
detoxification, methadone is administered in higher doses, but given less
frequently. A typical dose of methadone during this regimen would be an
initial dose between 15 mg and 40 mg, taken one time a day. The disket
typically contains between 20 mg and 30 mg of the medication at once,
although the patient should not receive more than 30 mg to 40 mg at a time
when first starting to use diskets. Because the diskets only come in specific
doses, they are not an appropriate option for patients who need doses that
fall outside of their availability. For example, if a patient requires 35 mg of
methadone but the diskets are only supplied in 10 mg doses, the patient
should not use diskets and should instead be prescribed methadone in liquid
form where the dose can be closely regulated.
Oral tablets of methadone offer advantages and disadvantages, as with any
other medication. Compared to diskets, tablets could be cut in half if they
are scored or cut by a pharmacy, providing a concentration of the drug that
22
is much closer to the prescribed amount. Alternatively, when a patient
requires an amount that is the same as the formulation, diskets or tablets
can be easily administered. The prescribing provider must always compare
the benefits of using this type of methadone with its risks of administration.
Contraindications
Administration of methadone requires close monitoring of the patient for
factors present that are contraindications to its use. A patient with certain
health conditions, such as asthma or breathing problems, allergy to the
drug, or certain gastrointestinal conditions should not take methadone at all.
There may be some situations in which a patient takes methadone and later
develops side effects or complications from the drug, but the healthcare
provider must then manage these as they occur if they are unforeseen.
Although methadone is usually administered within a controlled setting and
has specific purposes, the user can still develop some side effects that
should be monitored closely to prevent serious consequences. Side effects of
methadone include nausea and vomiting, restlessness, itching, sweating,
and constipation. Long-term side effects have caused breathing problems
and chronic respiratory conditions. Among women, methadone has been
shown to cause side effects of menstrual irregularities, and complications
with pregnancy if the patient is pregnant while taking the drug.12
Although there are side effects associated with methadone use, they may be
well controlled if they are monitored closely by a healthcare provider; in
some cases, other medications may be given to combat the side effects,
such as with administration of medication to control nausea if the patient
develops nausea and vomiting as a methadone side effect. At other times,
the methadone dose may need to be adjusted, depending on the severity of
23
the effects. While side effects may complicate methadone administration,
the patient may still receive the drug, even if they are present. When
contraindications are present, the patient should not receive methadone at
all. The patient should be evaluated for the presence of these
contraindications before starting methadone and should stop taking the drug
if these conditions develop during drug administration.
Allergy
Any patient who has an allergy to methadone should not be given this drug
and another type of drug should be administered instead. If the patient
already knows that he or she has an allergy to methadone, the provider
should refrain from administering the drug at all. An allergic reaction to
methadone can cause hives, difficulty breathing, or swelling in the face,
including in the lips, the tongue, or the throat. Some hypersensitivity
reactions have been reported in patients who have taken methadone and
who developed these symptoms. The healthcare provider should educate the
patient about signs of allergic reaction to methadone and instruct on what to
do if these symptoms develop.
In some cases, a patient may not be aware that he or she has an allergy to
methadone and may begin to take the drug, which ultimately causes an
allergic reaction. When this occurs, the healthcare provider must then treat
the condition as it has developed and manage the patient’s symptoms to
prevent additional complications. There should be no further administration
of methadone after symptoms of an allergic reaction have developed.
An allergy to methadone is considered whether the patient understands that
an allergy to the actual drug or to one of the components of the drug
actually exists. For example, a patient may tell the nurse that no allergy to
24
methadone exists, but that he or she has had an allergic reaction when
taking other types of opioids. If this occurs, the provider should further
investigate the patient’s allergy before administering methadone.
Additionally, trade names differ from generic drug names and the patient
may be familiar with only one form. For instance, a patient may inform the
nurse that he or she has an allergy to Dolophine, but may not understand
that this drug is the same as methadone. It is the responsibility of the
healthcare provider to educate the patient in these and other situations
where potential allergy exists to keep the patient safe and prevent severe
complications.
Breathing Problems or Asthma
Respiratory depression is one of the major risks associated with use of
methadone; respiratory and cardiac deaths have occurred when patients
have started taking methadone as a new drug or when converting to
methadone from using another opioid drug. There are several factors that
can increase the risk of respiratory depression developing in the patient who
takes methadone, which should be considered before prescribing this drug.
Patients who have a history of substance use with more than one drug, older
adults, are immunocompromised, and those who have either never used
opioid medications before (called opioid naïve patients), or those who have
used excessively high doses of opioid drugs in the past, are all at higher risk
of developing respiratory depression when using methadone.21
Because of the potential for respiratory depression when taking methadone,
it is important to avoid use of this drug in any patient with a history of
respiratory illnesses, chronic lung disease, or asthma, as methadone could
further complicate the course of these illnesses. The effects of respiratory
25
depression tend to develop after the drug’s analgesic effects set in, and the
respiratory effects can last much longer than the analgesic effects, which
makes dosing this drug very difficult. A patient could receive a dose of
methadone for pain and, after an hour, complain of little to no pain relief
with the drug. If the nurse administers another dose of methadone to
counter the patient’s pain, he or she may eventually experience pain relief
from the analgesic effects but could also develop respiratory depression
much later from the cumulative administration of the drug. The respiratory
depression happens late enough that the provider may not be aware of its
effects until the patient has received more than one dose of methadone.
Patients with conditions such as asthma, chronic obstructive pulmonary
disease, cor pulmonale, cystic fibrosis, or any other respiratory condition
that already makes breathing difficult should not be given methadone or it
should be administered with extreme caution. Any patient who takes
methadone for pain control should be monitored closely for respiratory
depression, particularly while sleeping. A patient with a respiratory condition
should be monitored while sleeping regardless of his or her level of tolerance
for opioid medications while taking methadone. Further, the provider should
monitor the total amount the patient receives daily when a respiratory
condition is present to prevent toxic levels from accumulating; the provider
should not increase the dose of methadone for pain medication more often
than every 7 days and at no more than 25 to 50 percent of the original dose
if using it for pain control in a patient with asthma or chronic lung disease.21
A patient who experiences respiratory depression and who is taking
methadone may develop symptoms of slow or shallow breathing, difficulty
taking in enough air with each breath, fatigue, sleepiness, confusion, and
dizziness or lightheadedness. Methadone use can also affect a patient’s
ability to breathe while sleeping, which can be particularly dangerous if the
26
patient takes the drug before going to bed. Methadone could cause slow or
irregular breathing during sleep, or even periods of apnea.
A case report in the Journal of Clinical Sleep Medicine discussed the effects
of opioid use on breathing and sleep, stating that patients who take
methadone and other opioid medications are at higher risk of developing
central sleep apnea with regular medication use. Central sleep apnea
develops when there is interference when the brain sends signals to the
body to continue breathing while asleep. Because of the increased risk of
respiratory depression among patients who take opioid analgesics, a drug
such as methadone can increase the risk of central sleep apnea. The case
study further elaborated that when eliminating opioid therapy in a patient
with central sleep apnea, the patient no longer experienced periods of apnea
while sleeping.22 This does not necessarily mean that any patient with
breathing difficulties who discontinues taking methadone will have resolution
of breathing problems, but it does point out the relationship between some
breathing disorders and opioid medications such as methadone.
The patient with a respiratory issue such as asthma may also experience
difficulty breathing and a slowed breathing rate when taking methadone. A
person with asthma already struggles with chronic and periodic inflammation
of the airways that can cause them to constrict, leading to wheezing and
shortness of breath. The respiratory depression caused by methadone could
potentially worsen symptoms of asthma and result in decreased respiratory
drive and increased airway resistance, making it very difficult for the patient
to breathe and potentially leading to apnea and respiratory failure.
27
Paralytic Ileus
Ileus is the term used for an intestinal obstruction that is not caused by a
blockage in the gut. A paralytic ileus refers to a condition in which the
intestine is not working properly and this paralysis is what causes the
obstruction, preventing movement of food through the digestive tract.
Paralytic ileus is a common cause of obstruction in children, although it can
develop in anyone of any age. It most commonly develops as a complication
following abdominal surgery or from gastroenteritis because of a bacterial or
viral infection. Other potential causes of paralytic ileus include chronic use of
opioid analgesics, electrolyte imbalances, and mesenteric ischemia.
A patient with paralytic ileus typically experiences nausea, constipation, and
feelings of abdominal fullness or bloating. Diarrhea, excess gas, and
cramping may also be present. It typically requires treatment by placing the
patient on NPO status and inserting a nasogastric tube for stomach
decompression. This relieves the abdominal bloating and excess gas buildup
in the intestinal tract and allows for bowel rest, which can help to resolve the
condition over time or with treating causative factors.19
One of the side effects of methadone use, as with many other opioid
medications, is constipation. Opioids such as methadone can cause
constipation when they cause an increase in water and electrolyte absorption
from the intestine and when intestinal peristalsis is slowed to the point that
stools become hard and dry and are difficult to pass. Some of the M
receptors affected by methadone are found on the smooth muscle of the
intestine and play a role in maintaining appropriate intestinal motility. This
may better explain how an opioid such as methadone could cause a slowing
of intestinal motility when it affects these receptors, potentially leading to
28
severe constipation or complete cessation of motility through paralytic
ileus.20
A patient who already has a diagnosis of paralytic ileus should not be given
methadone to avoid exacerbating the condition. The provider should
consider whether administration of any kind of opioid analgesic is valid for a
patient with paralytic ileus, as opioid analgesic medications share the
common complication of causing constipation. If a patient has a history of
paralytic ileus, the provider should consider other forms of analgesia for
treatment and should avoid methadone.
Methadone and Addiction
Despite its success as a form of treatment for those suffering from opioid
addiction, methadone can and does lead to a substance use disorder among
some patients. The problem with using methadone to treat certain addictions
is that sometimes the patient transfers addiction for a substance to the
methadone. For example, a patient addicted to heroin may go through
detoxification using methadone and may overcome heroin addiction only to
become addicted to the methadone and then might fear stopping the drug.
When this occurs, the person may develop enough of a methadone
substance use disorder that withdrawal symptoms are experienced when
attempting to stop using it.
The effects of methadone can vary depending on its purpose. Methadone
given for pain relief provides an analgesic effect for up to 8 hours, but when
given to avert narcotic withdrawal symptoms, its effects may last much
longer. People who take methadone may be at higher risk of developing a
substance use disorder and addiction because it lasts such a long time. Even
29
after discontinuing the drug, small amounts of the drug are still found in the
body.
Because methadone is often used to treat an existing substance use disorder
and addiction, the patient may or may not address the addictive aspects of
his or her personality or the reasons for developing a substance use disorder
and addiction in the first place. This creates problems if the patient then
transfers his or her addiction to methadone without actually addressing any
underlying needs. Patients who become addicted to methadone while
undergoing substance use treatment have used the drug while in treatment
or have used it in other inappropriate ways. For example, some patients may
take extra methadone and sell some of it outside of the treatment facility, in
a process known as diversion. Patients enrolled in methadone programs take
advantage of their access to methadone for treatment and end up getting it
and selling it to opioid drug users who are willing to pay for it. This results in
further danger when the person buys the methadone to feed an addiction
and ends up taking too much and overdosing. The number of overdose
deaths due to methadone administration has been increasing in the past
decade.
Although methadone treatment can lead to addiction, the patient who uses
methadone under close supervision of a healthcare provider is less likely to
become addicted and may use it successfully. When the patient is given
methadone regularly to combat cravings for other drugs, he or she may
develop a tolerance for methadone and may require more of the drug to get
the same effect. Persons at greater risk of developing a methadone use
disorder and addiction are those who have a history of opioid drug or alcohol
addiction, especially those with addiction to more than one substance. The
30
risk of overdose and death from methadone use is much higher among
individuals who struggle with substance abuse.
Methadone is also misused outside of the healthcare environment; because
of its opioid effects, methadone is classified as a Schedule II controlled
substance, which gives it a high potential for abuse. In 2012, over 2.46
million people in the U.S. reported using methadone outside of its intended
purpose at least once during their lifetime.14 The potential for addiction and
overdose on this drug is very high, which makes it dangerous as an illicit
substance.
Withdrawal Symptoms
Misusing methadone can have serious consequences for the person who
becomes addicted to this drug. A patient may begin taking methadone as
part of a detoxification program for another type of drug addiction but may
then end up abusing methadone instead. Although methadone does not
cause the same effects as some other drugs such as heroin, the person who
uses methadone may initially experience a high when using it.11 Over time,
the high that first came with using methadone is diminished because the
person has developed a tolerance for the drug. Instead of feeling euphoric
and high, the person may just feel tired and drugged.
If the patient is taking methadone in an outpatient setting, he or she may be
at risk of addiction and overdose if administration of the drug is not well
controlled. The person may develop a tolerance for methadone over time
and in order to experience the high again, he or she may start taking more
of the methadone doses than is prescribed. This can greatly increase the risk
of toxicity, overdose, and even death.
31
An individual who is abusing methadone may have signs or symptoms that
are similar to a substance use disorder and addiction to other opioid drugs.
Signs or symptoms of methadone use include difficulties with sleeping,
confusion, lethargy, drowsiness, nausea and vomiting, and chronic
constipation. The person may complain of itchy skin or may have difficulties
with carrying on a normal conversation, often losing track of the subject or
talking about irrelevant topics. A patient who ingests too much methadone
may experience severe bradycardia, somnolence, hypotension, cool skin,
and slowed respiratory rate leading to periods of apnea.
High doses of methadone have been shown to cause cardiac changes of
prolonged Q-T intervals as seen on ECG, resulting in the dysrhythmia
torsades de pointes. Patients who are more likely to develop this potentially
life-threatening cardiac condition are those who already have a history of
heart disease or cardiac arrhythmias, those who take cardiac medications,
and people who have electrolyte imbalances. For various reasons, this
cardiac outcome also seems to affect women more often than men and may
be more likely to develop among patients who have pre-existing liver
disease, and among patients who already take higher dosages of
methadone. The patient who takes too much methadone can eventually
develop pulmonary edema, lapse into a coma, or die from respiratory failure.
Methadone side effects and withdrawal symptoms are much less likely to
occur if the patient is closely monitored while receiving the treatment. If the
person develops a methadone substance use disorder and addiction, and
starts developing withdrawal symptoms, the symptoms are typically not as
severe as with heroin or other types of opioid withdrawal; however, they are
still uncomfortable for the patient and could lead to severe complications if
32
they are not well managed. As stated above, one option for dealing with
methadone withdrawal is medical marijuana.
Medical Marijuana
Marijuana, also called cannabis, is a flowering plant that is used for a variety
of purposes. The main plant used for medical marijuana comes from the
hemp plant Cannabis sativa. Its leaves and stalks have been used for such
items as paper, clothing, or rope, but most people think of marijuana as
being used for ingestion, which produces mind-altering effects. Because of
these effects, the growth, sale, and consumption of marijuana is regulated
and is considered illegal; however, marijuana is becoming more popular
when used for medicinal purposes.
There are many varieties of marijuana, although the central image often
associated with it is a picture of a plant with 5 broad leaves. Marijuana may
be grown on a stalk or as a type of bush; it is cultivated and grown under
careful conditions, but it may also grow in the wild. Most forms of the plant
develop flowers if allowed to multiply and grow on their own without being
cut; these flowers can also be used for medicinal purposes and they produce
the effects of the drug. The dried flowers that grow on the plant are often
referred to as buds.
The main ingredient in marijuana that causes mind-altering effects is delta9-tetrahydrocannabinol (THC); the effects of THC can vary, depending on
the strain of cannabis. People who use marijuana for recreational purposes
often say that it makes them feel energized, focused, creative, and calm,
coupled with a better overall sense of well being. The effects of the drug are
different from what can be gained from ingestion of almost any other legal
substance, which is why marijuana is so commonly sold and used as an illicit
33
drug. THC is classified as a cannabinoid, which is a chemical compound
found within the cannabis plant. The amount of THC actually varies from
plant to plant. In addition to THC, marijuana contains over 100 other types
of cannabinoids that act on the release of neurotransmitters and can affect
feelings of pleasure, pain, awareness, and appetite. The body also produces
some cannabinoids that have these same effects.
Delta-9-tetrahydrocannabinol has been shown to be effective in controlling
nausea and improving appetite, which is why medical marijuana can be
useful for patients who suffer from intractable nausea due to medical
treatments, such as with chemotherapy for cancer. The effects of THC are
also beneficial in preventing malnutrition, dehydration, and possible
hypovolemia for those who suffer from severe nausea and vomiting because
of the effects of illness. Medical marijuana may also help those who are
malnourished because of disease and who need to gain weight, such as
those who are suffering from wasting disease during the later stages of
AIDS. THC has also been shown to be effective in controlling pain,
particularly neuropathic pain such as that seen with post-herpetic neuralgia,
as well as the control of inflammation when used among some people,
including those who suffer from arthritis.
Marijuana also contains another type of cannabinoid, known as cannabidiol
(CBD), which may be useful in the management of some medical conditions
as well. Researchers have been developing forms of CBD to administer as
treatment for seizures; CBD may also be useful in managing pain,
inflammation, and some types of mental illness or addictions.5 Unlike THC,
CBD does not produce the mind-altering affects associated with marijuana
use; it can provide many of the same benefits as THC but without the
psychoactive effects. This may reduce the likelihood that medications
34
created with CBD will be abused. Other cannabinoids found in marijuana
have been shown to control intraocular pressure associated with glaucoma,
to act as mild sedatives, to have antimicrobial properties, and possibly to
reduce some of the negative effects of type 2 diabetes.6
The National Institute on Drug Abuse defines medical marijuana as “use of
the whole, unprocessed marijuana plant or its basic extracts to treat a
disease or symptom.”5 Most marijuana that is used for medicinal purposes is
the same that is sold and used as the illicit drug. Medical marijuana also has
some of the same health risks as the street drug. In the past, patients who
suffered from illnesses or chronic diseases that did not respond to traditional
forms of treatment or medications may have found relief by using
marijuana. Unfortunately, because of marijuana’s legal status, patients using
marijuana had to break the law to be able to achieve relief from their
symptoms.
Before 1937, marijuana was routinely used as medical intervention and for
control of various symptoms, including anxiety and pain. In fact, people
have been harvesting marijuana for use for physical ailments, pain, and
other illness symptoms for hundreds of years. However, legislation began
during the early 20th century that changed the use of marijuana, starting the
process of making its use for medicinal purposes illegal. Initial legislation
known as The Marihuana Tax Act of 1937 placed restrictions on the
medicinal use of marijuana, but it was not until 1970 that marijuana was
completely prohibited for use for medicinal purposes with the passage of the
Controlled Substances Act of 1970.2 Since that time, there have been some
marijuana-based pharmaceuticals on the market, but these types of drugs
have been classified as controlled substances. An example is dronabinol
(Marinol®), which is used to treat nausea and vomiting among some
35
patients with cancer or to support weight gain among some patients with the
wasting disease of AIDS.
Dronabinol is considered to be a cannabinoid medication and is classified as
a Schedule III controlled substance. The herbal form of marijuana is
considered a Schedule I substance according to the Schedule of Controlled
Substances; the drugs classified in this category are those that are seen as
having a high potential for dependencies and not having medical use.
Examples include other narcotics such as heroin or lysergic acid diethylamide
(LSD).
The Schedule of Controlled Substances is a federal-level classification of
drug and opioid use, and although herbal marijuana remains classified in this
category, there have been changes in legislation that have allowed its use
for medicinal purposes, but these changes have occurred at the state level.2
In other words, the federal government still classifies marijuana as a
controlled substance with no medicinal purpose, but individual states are
changing their laws to legalize marijuana for medical purposes. Since 1996,
23 states and the District of Columbia have approved public medical
marijuana programs.3 Each state has their own specifications about its use
and most patients who use medical marijuana must carry an identification
card that designates their ability to have marijuana for medicinal purposes.
When a patient would benefit from medical marijuana, a physician can make
a recommendation for its use as part of treatment. This recommendation
differs from an actual prescription for marijuana. Healthcare providers
cannot actually prescribe marijuana because it is a Schedule I controlled
substance, but they can make recommendations based on the laws of their
state. If medical marijuana is allowed within a specific state, the healthcare
36
provider’s recommendation would then allow a patient to get an ID card,
which allows the patient to buy marijuana for medicinal use.4 The ID card
places the patient on a registry that also protects him or her by stating the
purpose of possessing marijuana to avoid penalty.
Medical marijuana is not available at a pharmacy as with other medications.
A patient with a recommendation for medical marijuana receives what is
needed from a dispensary or, in some cases, what can be grown. The
amount of marijuana to grow and the growing conditions used for medical
marijuana varies between states. Marijuana grown in a dispensary is
controlled in terms of growing conditions, drying, curing, and preparation. In
these facilities, cannabis is grown and harvested with attention to soil
conditions, appropriate heat and air circulation, and properly controlled light.
Companies that grow cannabis that will be used for medical purposes have
controls and requirements related to pesticide use on the plants, as well as
other chemicals used to control growth or prevent disease. Because some
patients who later use the cannabis for medical purposes may be
immunocompromised, use of these chemicals is strictly controlled and
enforced.1
Alternatively, a patient may also be able to grow his or her own marijuana
for use, which may or may not be up to the same standards of quality as
that be grown in medical dispensaries. Those who want to grow marijuana
may use areas of their own homes, and can grow the plants using grow
lights or natural sunlight. However, there are a multitude of laws and
regulations surrounding the process and not just anyone can legally start to
grow their own. To be able to legally grow medical-grade marijuana, the
grower must adhere to the guidelines, zoning regulations, and laws of his
state and area of residence.
37
Uses of Medical Marijuana
As stated, medical marijuana can be used for a variety of medical conditions.
Proponents of the drug say that legislation prevents people who really need
help for their symptoms and illnesses from getting the medication they need
that can alleviate symptoms. Those who are advocates of medical marijuana
legalization state that people suffer needlessly when they could actually be
helped or even cured by using marijuana if it were made legal everywhere.
Alternatively, those who are not in favor of its legislation remind others that
it is still a controlled substance that must be carefully regulated, and
legalization of the drug may only support its misuse.
Regardless of its legal status, research and anecdotal evidence have shown
that it is beneficial as treatment for a number of conditions. Such conditions
include intraocular pressure associated with glaucoma, management of
spasticity due to some neurological diseases, treatment of mental health
conditions such as depression or anxiety, and multiple other conditions that
cause pain, inflammation, memory problems, nausea, weight loss, and
fatigue.
Delivery Methods
Marijuana may be ingested in a number of methods, but there are basically
four main ways that the drug is consumed; orally, through inhalation,
sublingually, and topically. Each method of consumption varies in the way
the drug is delivered and the method each patient chooses to ingest medical
marijuana will depend on several factors, including personal preference, the
conditions for use of medical marijuana, and the availability of the drug. The
majority of consumers choose inhalation, or smoking, as the method of
choice for ingestion of marijuana, but patients do have other options
38
available, and those who choose not to smoke or who are seeking other
methods of ingesting the drug may consider alternative delivery methods.
Inhalation
Inhalation of medical marijuana is one of the most common forms of
ingestion. The effects of the drug, when used with inhalation methods, are
felt much more quickly when compared to other forms of ingesting
marijuana. This can be beneficial for a patient who is in severe pain or who
suffers from significant nausea and who needs relief quickly. Smoking also
averts the need for the patient to take oral pills and medication, which the
patient may or may not be able to keep down if nauseated. Inhalation is also
beneficial in that the user has some amount of control over how much is
taken in by choosing how much to smoke; in this method, the risks of
overdose and overconsumption are much less when compared to some other
methods of ingestion.
Inhalation of marijuana is typically done by either smoking or through the
use of a vaporizer. There are several methods that allow a person to smoke
marijuana. Some are inexpensive and easy to do, while others require
equipment and practice. Inhalation may use different parts of the marijuana
plant as well, and some activities, such as smoking, use cut up pieces of the
plant, while pipe smoking or vaporization may use oil of extractions.
Extractions contain the active ingredient of the marijuana plant without any
of the plant material. Extractions are available in various forms and include
such types as cold water extraction, dry tumbling extraction, or direct
contact.
39
Smoking
One of the most well known methods of smoking marijuana is with a
cigarette or cigar. Sometimes referred to as a “joint” or a “smoke”, this
method of inhalation is cheap and easy for the user. Marijuana is typically
provided as cut leaves and a small amount is placed within a square of paper
for rolling. These papers are inexpensive and the process of rolling a
marijuana cigarette is relatively easy and does not require further
equipment. After rolling and securing the cigarette, the individual lights the
end of the cigarette to produce smoke and uses it in much the same manner
as when smoking a tobacco cigarette.
Marijuana may also be inhaled through pipe smoking. There are various
forms of pipes used for smoking marijuana and they vary between small,
handheld devices that hold only a small amount at a time to large pipes that
can be used for long periods or shared between users. Small pipes typically
have a bowl on the top, in which the marijuana is placed; after lighting, the
individual can then smoke what is in the bowl of the pipe. A pipe that holds a
very small amount might be known as a “one-hitter,” meaning it is designed
to hold enough for one dose of the drug. Pipes can be made out of a variety
of materials, including glass, acrylic, stone, or metal.
The water pipe is another type of pipe that can deliver marijuana smoke for
inhalation. These pipes also act as filters and require a small amount of
water placed in the base. As with standard pipes, they can be very large in
size or quite small. A water pipe has a stem that exits the system;
marijuana is placed in this stem, which leads down to the bottom of the pipe
where there is water. The person smoking inhales from the top of the pipe,
which pulls the smoke down the stem and into the water; the chamber
above the water that leads up to the smoker’s mouth then fills with smoke,
40
which is then inhaled. The water acts as a type of filter so that when the
smoke passes through the water chamber, it removes some of the toxins in
the smoke before the person inhales it. Water pipes are often called “bongs”
or “bubblers.”
Hashish is a form of concentrated marijuana that is inhaled through a pipe,
although it can be added to food as well. Hashish contains compressed resin
glands of the marijuana plant, which comes in the form of a paste. It
typically has a higher concentration of cannabinoids, but the range of THC
present varies within the concentration as it does in a standard plant. Hash
oil is extracted from a mature marijuana plant and contains a high
concentration of cannabinoids; in some cases, up to 90 percent THC by
content.6 Hash oil can be smoked through a special type of pipe or inhaled
through a vaporizer.
Smoking marijuana for medicinal purposes causes a rapid response because
the THC quickly enters the system. Many patients prefer smoking marijuana
because they experience the effects quickly, which can be favorable when
experiencing very negative symptoms such as pain or nausea, which could
be resolved quickly with smoking. When smoked, the THC in marijuana is
absorbed within only a few minutes, and studies have shown that this rapid
absorption and distribution of THC is almost equal to the rate at which the
chemical would enter the system if it were injected intravenously.28
As with smoking other substances, inhalation of marijuana can cause
negative effects and damage to lung tissue. Marijuana does not contain as
many toxic substances when compared to smoking tobacco, however,
smoking marijuana still produces smoke that is irritating to lung tissue and
can cause coughing, increased mucous production, and can alter effective
41
gas exchange. Experts recommend that patients who smoke marijuana for
medicinal purposes inhale as little of the drug as possible to reduce the
effects of smoking on the body. A patient who inhales marijuana for
medicinal use may notice results so quickly that he or she does not need to
smoke for very long and may only need to inhale a few times. Following this
practice could lessen damage to the lung tissue that would otherwise
develop from chronic smoking.
Vaporization
Inhalation of vapors is considered to be a much safer form of marijuana
ingestion when compared to smoking because the vapors created do not
contain tar or other chemicals found in marijuana smoke and are less
irritating to the lung tissue. Vaporization is one of the most efficient methods
of inhaling marijuana. The process involves heating the marijuana to the
point of turning the cannabinoids to vapor, which is not at as high of a
temperature when compared to smoking marijuana. The person who wants
to use marijuana through vaporization typically must buy the equipment,
and there are many varieties of tools available for vaporizing.
Inhaling marijuana vapors, also known as vaping, is similar to using an
electronic cigarette. This device contains a filter that has liquid flavoring and
the substance within it; when the person inhales on the end of the vaporizer,
the filter heats up and turns the liquid to vapor. This vapor is not smoke,
although it may be similar in appearance; instead it is a collection of tiny
particles of the cannabinoids that have been changed from a liquid state to a
gas state, which can then be inhaled into the lungs. The vapor contains the
chemicals in marijuana that are used for treating symptoms and illness but it
does not contain harsh chemicals such as tar, which would be found in
smoke when marijuana is burned.
42
The downside of vaping marijuana is that there is little information about the
continuing effects of its use. While the effects of long-term smoking of
marijuana have been studied, inhalation through vaporizing is a newer
phenomenon in the U. S. and has fewer outcome results that have studied
people who have used this method of marijuana consumption for long
periods.9 This is partly because the parts of the marijuana plant used for
vaporizing are the extracts, as opposed to the flower, which is more
commonly burned when smoking marijuana.
Vaporizers for marijuana inhalation may be small and about the size of an ecigarette; these devices are hand held and may be referred to as “pens,”
which are battery powered. Vaporizers can also range in size and can be
quite large or designed to sit on a counter or desktop. Vaping has not only
been shown to be safer than smoking marijuana because of decreased lung
irritation, but it also has been said to taste better and it avoids the
characteristic smell of the drug. However, although vaping may reduce lung
irritation and exposure to some toxic chemicals that occurs with smoking
marijuana, the person who uses vaporized marijuana for medical treatment
is still exposed to its psychoactive effects, which could be harmful.9
Sublingual
Sublingual preparations of marijuana are prepared and administered into the
mouth and under the tongue, where they are quickly absorbed into the
bloodstream through the sublingual mucous membranes. The blood vessels
in the mouth, particularly those found under the tongue, are able to readily
absorb cannabinoids found in the sublingual forms of marijuana. Types of
sublingual products may be delivered via lozenges, sublingual spray, or
medicated strips that are placed under the tongue to dissolve. Sativex®,
described later in this course, is a type of sublingual spray used for the
43
management of spasticity associated with multiple sclerosis. The patient
sprays the dose of the drug under the tongue and then closes his mouth
while the drug is being absorbed. When administered in sublingual form, the
effects occur rapidly as the drug quickly enters the bloodstream.
Sublingual doses can be effectively regulated, which prevents the patient
from overdosing by taking on too much. In fact, some companies who make
and market cannabis sublingual products offer a variety of concentrations in
their products, with each product containing different amounts of THC and
cannabidiol. Patients can choose and adjust the amount of THC and CBD that
they would like when choosing a product, which is then delivered with each
dose.
Sublingual products, like oral forms of marijuana ingestion, are discreet and
patients who need them can easily use them. A patient who uses a
sublingual product can simply place a lozenge or medicated strip under the
tongue where it is hidden from others. A sublingual spray can also be easily
administered and appears similar to breath spray. The sublingual method is
most rapidly absorbed when compared to absorption through other blood
vessels in the mouth, including those vessels lining the buccal cavity. The
patient should typically feel the effects of the sublingual medication within
15 to 60 minutes.
Patients who use sublingual preparations have reported that the effects of
the drug often cause uplifting and energizing feelings, as opposed to the
sedative effects that sometimes occur with marijuana use, but responses do
vary between patients. The patient should be taught that when using a
sublingual preparation, if it requires placement of a tablet or lozenge under
the tongue to dissolve, he or she should let the medication dissolve
44
completely to gain the full effects of the drug, rather than trying to swallow
any part of it. When used correctly and for appropriate reasons, sublingual
marijuana preparations are a very effective choice for drug administration.
Oral Forms
Oral forms of marijuana are available with many variations; while cannabis
is typically ingested orally through food, known as edibles, or when drunk in
liquid form, such as with tea, there are also other methods of oral ingestion,
including tinctures, capsules, or oils. One of the most common methods of
oral ingestion is through mixing elements of marijuana with certain foods to
create desserts or products that the patient can eat and can then derive the
benefits of the drug.
Marijuana Edibles
Edible forms of marijuana found in foods are often available through baked
goods, sweets, and cooked items in which the cannabis has been added as
part of the food preparation process. The THC in cannabis is not active
unless it is heated first, which converts the cannabinoid into the active form
of THC. There is a large amount of variety when it comes to edible products
that contain cannabis that can be taken for medicinal purposes. Some
dispensaries or locations that sell edible marijuana products provide a
variety of products for purchase, all of which contain varying amounts of
marijuana within the food recipe. These edibles may be packaged and
marketed as not only providing medical marijuana to treat diagnosed health
conditions, but also as being tasty, sweet, delicious, or otherwise appealing
to entice the consumer into purchasing these products as a method of
ingesting the marijuana.
45
Edible marijuana takes longer to absorb when consumed orally through
edible products, but the effects of it can last longer when compared to other
methods of ingestion, such as through smoking. Because of how the
cannabinoids are metabolized after ingestion, a different form of THC is
formed in the liver during digestion, which can cause varying effects
between individuals. A person who ingests edible cannabis will not feel the
effects as quickly as if he were to smoke marijuana, and it may take at least
20 minutes to feel the full effects. However, when they do develop, the
effects of ingesting marijuana in this method are much stronger when
compared to smoking and they last longer.7
The method of adding cannabis to the particular edible also varies,
depending on the food in which it is found and how the cannabis is available.
Most edibles are some type of baked goods, such as brownies, cookies,
sweet breads, or bars. The cannabis is added through a special type of
butter that has been infused with marijuana. Cannabinoids can be dissolved
into solutions that contain fats, such as butter or oil, which can then be
easily added to products during the cooking process. Cannabis oil is also
added to foods, including baked products or almost any other food that
requires oil as one of the ingredients. The oil known as cannaoil is created by
mixing and heating the cannabis and oil together; the plant material is then
strained out of the mixture but the medication is otherwise infused into the
oil where it can be included in cooking.
Hashish, hash oil, and hash-infused butter may also be added to baked
goods to create edibles. Because of the higher concentration of cannabinoids
found in a smaller amount of hash, less needs to be added to the food to
create the same effect. Alternatively, the addition of hash may create an
even stronger or longer-lasting effect when compared to the addition of
46
standard amounts of cannabis. Depending on the amount of cannabis added
and the method in which it is infused into the product, the patient may or
may not be able to taste the marijuana when they eat it. Many people who
can taste the cannabis while eating edible products say that they do not like
the taste and that it is not as enjoyable as when smoking or inhaling
marijuana.
Patients who use edible products to consume medical marijuana typically
access these items through the dispensaries where they would obtain other
forms of cannabis. Some growers of medical marijuana plants have jumped
on the chance to increase income by creating and providing edible marijuana
in addition to other forms in which it can be ingested. By providing a line of
products, such as baked goods and snacks that contain cannabis for
medicinal use, they provide medical marijuana for patients who need it but
also earn extra money by including a service for some patients without
access to marijuana. Many patients who have a recommendation for and use
medical marijuana could make their own foods to consume the drug. As with
other foods on the market, though, people often opt to buy the food premade to where they can eat it, rather than preparing it themselves ahead of
time.
Edible marijuana products can be risky for some patients, particularly those
with less experience in using them. The amount of marijuana in each item
may impact the person consuming it differently when compared to someone
else who takes the same amount. A patient may have heard that someone
he or she knows used a particular type of edible marijuana and had good
results for an illness, but the patient may have a higher tolerance when
using the same item and may not achieve the same results. Furthermore,
because edible marijuana takes longer to digest, and for the patient to start
47
to feel its effects when compared to smoking marijuana, the patient may
reason that the edible marijuana is not effective and more should be eaten,
which could lead to ingesting unsafe amounts of the drug.
Because edible marijuana products are often made up of sweets and
desserts — which can be difficult to refuse even when they do not contain
cannabis — some people may have trouble eating only one. Because these
items often contain butter and oil, intake of too much can lead to poor
health outcomes, including higher cholesterol and weight gain in excess of
the potential overconsumption of marijuana when eating too much. A person
who wants to use edible marijuana, particularly when it is provided in the
form of baked goods or sweets, would most likely respond best by eating
small amounts and going slowly, waiting for the effects to develop, rather
than eating more.
A patient who decides to use edible marijuana to treat a condition may find
that this method of ingesting the drug works very well. Edible products can
be more discreet when compared to smoking cannabis and many people
enjoy the taste, which can make taking the drug easier. For those who
cannot smoke or who use oxygen where it would not be safe to smoke,
edible marijuana provides an alternative method of ingesting the drug. And
for those who use marijuana to gain weight, edible products provide not only
appetite stimulation, but also extra calories or nutrients that could be
included with the food. Alternatively, in addition to the potential health
problems associated with eating too much, some edibles are very expensive
and could add up quickly in cost if oral products are the only method of
ingestion. The patient would need to weigh the benefits and disadvantages
of using this type of system when compared to consuming marijuana in
another manner.
48
Capsules and Tablets
Cannabis capsules may be available for some patients. These products
provide the medicinal outcomes of marijuana use while delivering the drug
to the patient in a more traditional and familiar manner - through a pill or
tablet. Because of the restrictions on smoking in some areas, people who
use medical marijuana may benefit from using the edible form, such as with
edible foods or with capsules, instead of trying to smoke when consuming
the medication in public.
As with marijuana found in baked goods and edibles, medical cannabis
ingested through capsules can take longer to produce the same effects as
when a person ingests marijuana through inhalation. A patient who takes a
capsule of the drug must first absorb the medication and utilize its properties
through the principles of pharmacokinetics before the actual effects of the
drug may develop. For example, two patients may ingest medical marijuana
for appetite stimulation; one patient chooses oral capsules as a method of
ingesting the drug while the other chooses to smoke marijuana to stimulate
appetite. The patient who smokes marijuana may be more likely to feel the
effects of the drug and may be encouraged to eat more at a faster rate
because the effects of the drug occur much more rapidly when compared to
the patient who uses oral capsules and who must wait while the drug is
absorbed and metabolized in the bloodstream. Alternatively, oral
preparations may last longer than when marijuana is ingested through other
forms, so these two same patients may experience the effects of the drug at
different rates; but, the patient who opted for oral capsules instead of
smoking may experience the effects of the marijuana for a longer period
when compared to the patient who chose to smoke the drug.
49
The peak effects of marijuana, when ingested orally, typically occur after
about 2 hours and may last as long as 6 hours.46 The capsules available as
forms of marijuana may vary between the prescription pharmaceuticals
available for treatment of certain conditions to actual cannabis preparations
available in tablet form. One example of this drug is Idrasil™, which is
considered a natural neutraceutical, which is a combination of “nutrition” and
“pharmaceutical,” and that describes a food or similar item that contains
medicinal benefits. Idrasil is referred to as a “naturally consistent cannabis
pill” that provides the benefits of using medical marijuana without the social
stigma involved with its use.46
Idrasil compares itself to other types of pharmaceutical marijuana
preparations, which are synthetic formulations of the plant. Alternatively,
Idrasil states that it contains all natural components of marijuana plant
extract so that users can derive the full benefits of cannabis in pill form
when it is prescribed. Idrasil is available as a 25 mg tablet that contains the
same, consistent amount of drug with each capsule, rather than the
potential for unreliable dosage amounts found in other methods of marijuana
ingestion, such as through edibles. For instance, Idrasil claims that when a
person chooses to use medical marijuana for treatment, he or she can be
assured that the same, standard amount of the drug is being received with
each dose when taking these capsules, but the same cannot be relied upon
when ingesting marijuana through other methods, such as through baked
goods that contain the drug.
Medical marijuana capsules are relatively easy to use and they are discreet
in that they appear similar to other types of medications. The patient may
take the capsules as prescribed and in the same methods as with other
drugs, by swallowing with medicine with a glass of water. Whether or not a
50
patient chooses this method of ingesting medical marijuana, capsules or
tablets provide easy access to the benefits of cannabis use in a familiar form
that mimics taking many other oral medications.
Oil
Cannabis oil is yet another form of ingesting medical marijuana orally. This
type of oil consists of distilled cannabis, in which most of the plant material
is removed through a solvent. The distillation process breaks down the
marijuana into its base form of active cannabinoids. Solvents used to break
down the plant into oil include alcohol-based products, including isopropyl
alcohol or even spirits used for alcoholic beverages.
Cannabis oil often contains a high concentration of THC, which can be very
potent for the user and that may be too much for a novice patient who has
little to no tolerance for the drug. The concentration is similar to that
described for hash oil. The oil also contains a certain amount of cannabidiol,
which does not produce psychotropic effects, but that does seem to have
anti-inflammatory properties.
Unfortunately, there are few scientific studies that support the claims that
cannabis oil is the miracle drug that many purport it to be. Anecdotally,
cannabis oil has been known to shrink cancerous tumors or send people with
late-stage cancers into periods of relapse when their prognoses were
otherwise grim.60 Because of the lack of scientific evidence about the healing
properties of cannabis oil, though, this product is still considered to be an
alternative form of treatment that may or may not be legal, depending on
the area where it is consumed.
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Topical
Beyond smoking or oral ingestion of medical marijuana, there are other
methods of taking in the drug for its medicinal benefits. Topical applications
of medical marijuana are available for the treatment of some skin conditions
and when a patient is experiencing pain. Topical applications are available in
creams, lotions, salves, bath salts, transdermal patches, and various
tinctures through a number of companies that provide testimonies and
stories about the effectiveness of marijuana when applied in this manner.
Topical marijuana preparations are created when cannabis is infused into
topical lotion or cream where it can then be applied to the skin. Topical
cannabis preparations are most commonly used for skin conditions that
cause inflammation, pain, swelling, or rash. Historically, topical cannabis was
used in the Middle East and in parts of Africa to act as an antiseptic, and was
applied to areas of the skin to kill germs and to prevent infection.47
These products work because marijuana dissolves in fatty substances. It can
then be absorbed through the skin and enter through cell membranes.
Furthermore, recent studies have shown that some of the cells in the skin
contain cannabinoid receptors, which would respond to topical application of
THC through the medication, potentially having a positive effect on skin
conditions.47 The seeds of the marijuana plant are made up of protein and
essential fatty acids, including linoleic acid, which may be helpful in the
treatment of some types of skin diseases, including psoriasis. Other parts of
the plant that may also be used as part of topical preparations include the
buds and leaves of the marijuana plant.
Some other conditions that may be helped through treatment with topical
marijuana include severe itching, osteoporosis, eczema, rheumatoid
52
arthritis, and other inflammatory diseases. Unlike eating or inhaling
marijuana, topical cannabis does not produce mind-altering effects and it is
less likely to be abused as a product. Consumers who use topical
preparations may prefer this method of using medical marijuana when
compared to other modes of administration, as topical preparations provide
relatively rapid relief of symptoms, such as with pain relief, and the patient
does not experience psychoactive effects.
Studies are just starting to be published about the positive effects of medical
cannabis when applied topically. Many patients offer anecdotal evidence that
topical cannabis has healed any number of skin conditions or painful
symptoms, but the actual scientific results of the drug administered in this
method continue to be investigated.
Pharmaceuticals
Marijuana pharmaceuticals are drugs that have been developed that contain
some amount of marijuana within their formulations. The amount of
marijuana present and the parts of the plant used vary between products.
Pharmaceuticals differ from neutraceuticals, such as Idrasil, in that
pharmaceuticals typically contain other combinations of drugs and are not
classified as being entirely natural. Marijuana pharmaceutical preparations
undergo a similar process as other drugs that are developed for the
pharmaceutical industry. They undergo clinical trials, are marketed to
consumers, and require FDA approval for use in the U.S. While there are a
variety of marijuana pharmaceuticals available, some are FDA approved at
this time, while others are pending or have not been approved.
Several of these cannabis-based drugs have been approved for use in the
United States to treat patient symptoms that are often associated with
53
certain health conditions. These cannabis pharmaceuticals are developed
and based on the premise that the marijuana within their formulations
provides many of the effects of the drugs. While many have been developed
and have undergone clinical trials for the treatment or management of
conditions such as obesity, memory loss, anti-tumor properties,
hypertension, and bladder control, there are currently only two marijuana
pharmaceuticals that have been approved for use in the United States. A
third drug is pending approval in the U. S. and is still being investigated, but
it has been approved in other countries.
Approved Pharmaceuticals
Dronabinol is a Schedule III narcotic that was approved by the U. S. FDA in
1985 for the treatment of nausea and vomiting associated with
chemotherapy administered for the treatment of cancer.28 The drug is
accepted for use after patients with nausea and vomiting have failed to
respond to treatment with other medications designed to control these
symptoms. Dronabinol was later approved in 1992 for use among patients
suffering from anorexia and weight loss during the later stages of HIV
infection and AIDS.
Dronabinol (Marinol®) is a cannabinoid drug that has been produced as a
synthetic form of THC. It works by impacting the medulla oblongata in the
brain, which controls nausea and vomiting. It is available in oral tablets with
a range of doses between 2.5 mg and 10 mg. When taken to control nausea,
dronabinol is effective for approximately 4 - 6 hours after each dose, which
typically requires repeated doses for the patient, depending on the amount
of nausea the patient experiences. When taken for appetite stimulation,
dronabinol is effective for a much longer period and may continue for 24
hours at a time, requiring much less frequent administration.
54
A study by Andries, et al., in the International Journal of Eating Disorders
demonstrated that dronabinol is effective in weight gain by stimulating
appetite not only in patients diagnosed with AIDS, but also in those who
have suffered significant weight loss because of anorexia nervosa. The study
showed that participants diagnosed with anorexia who took part in the study
had a greater amount of weight gain when compared to those who took
placebo.37 Since dronabinol contains synthetic cannabis, patients should be
advised to take it carefully to avoid misuse and the development of side
effects.
Patients with a history of a substance use disorder should be monitored
while taking dronabinol because of an increased risk of abuse of the drug,
and it should not be administered while taking medications that cause
sedative effects, such as benzodiazepines.38 Clinical trials have also shown
that use of dronabinol can cause a “high” feeling as a side effect, in which
the patient experiences elation and heightened awareness to surroundings.
While this effect does not occur in all patients who take dronabinol, it has
been shown to develop in some people whether they have taken the drug for
control of nausea or for appetite stimulation.
Nabilone (Cesamet®) is a Schedule II narcotic that is a synthetic form of
cannabis. As with dronabinal, the U. S. FDA approved nabilone in 1985 and
it is also used for nausea and vomiting. It is most commonly used for
management of nausea and vomiting associated with chemotherapy,
particularly when other antiemetic drugs have been unsuccessful. Nabilone
works by interacting with cannabinoid receptors in the body that affect the
central nervous system. The nerve cells that can cause nausea and vomiting
are typically located in the brain and the stomach. Nabilone sends messages
to the brain that prevent the start of nausea and vomiting.36 This method
55
differs from the action of traditional antiemetics, which is why it may be
prescribed when other drugs have been unsuccessful.
Nabilone is available as an oral tablet. The patient typically takes a dose
before starting chemotherapy, then the patient takes the drug throughout
the time he or she is receiving chemotherapy, and continues to take
nabilone for a prescribed period of time after chemotherapy is completed.
While effective in the treatment of nausea and vomiting, nabilone can still
cause psychogenic effects and can lead to changes in mental status. Patients
who take the drug should only do so in a controlled environment when
another person is near to provide care if they need it. A patient who takes
nabilone must also be careful not to drive or engage in activities that require
concentration just after taking the drug, as it can cause drowsiness or
dizziness.
Under Investigation
Nabiximols (Sativex®) is a marijuana pharmaceutical created from an
extract of the cannabis plant. It is manufactured in the United Kingdom,
where marijuana use is illegal for recreational purposes, but it can be used
for medicinal purposes in certain situations. Nabixoimols is most commonly
used to manage spasticity associated with multiple sclerosis (MS); a person
with MS who experiences increased muscle contractions, stiffness and
rigidity, and uncontrolled muscle movements may respond to nabiximols
because the drug affects the nerve impulses that cause spasticity.35
Although nabiximols has been approved in some countries, it is still
considered to be an investigational drug and has not been approved by the
FDA in the U. S. During clinical research trials, nabiximols was studied as a
potential adjunct medication to be used alongside some opioids for the
56
treatment of severe, intractable cancer pain. Whether nabiximols will
eventually be approved as a valid form of medical treatment for cancer pain
remains to be seen, but further research is still needed to prove its value
and to gain approval and acceptance in the U.S.
Contraindications
Regardless of the method of ingesting marijuana, patients should use the
drug carefully, particularly because its effects may differ between people.
Because not everyone responds to marijuana in exactly the same way,
improper use could be harmful for some people. There is a risk of taking too
much or engaging in dangerous activities after using medical marijuana. For
instance, although marijuana is said to be energizing for some, it may also
cause sedation and sleepiness for others. It may cause problems if a person
needs to focus or concentrate on a task. The person who uses marijuana for
medicinal purposes should use marijuana safely and in a well-controlled
setting, and should not drive or engage in any other activities in which harm
could occur until the effects of the marijuana have worn off.
Low Blood Pressure
Marijuana has been shown to affect almost every body system, including the
circulatory system and blood pressure. Because of these effects, cannabis
can cause a patient to suffer from symptoms of low blood pressure;
hypotension can develop in a person who uses medical marijuana, even if he
or she has not previously been diagnosed with low blood pressure. For an
individual who already suffers from hypotension and who has symptoms of
dizziness or episodes of fainting or lightheadedness, medical marijuana
would not necessarily be a first-line form of treatment of a health condition,
as the drug may only worsen hypotensive symptoms.
57
There is not one specific number that defines low blood pressure, but a
blood pressure level that is below the normal systolic and diastolic levels of
120/80 mmHg and that causes symptoms for the patient would be
considered hypotension. Symptoms of hypotension include dizziness,
lightheadedness, syncope, clammy skin, poor concentration, fatigue, blurred
vision, and thirst.
A study in the Journal of Addiction Medicine showed that patients who used
cannabis on a routine basis and then who abruptly stopped its use developed
a clinically significant rise in blood pressure, with a rise of over 22 mmHg
systolic and 12 mmHg diastolic levels noted.34 Marijuana acts as a smooth
muscle relaxant; when used, it lessens constriction in the blood vessels and
can cause vasodilation, ultimately leading to a lowering of blood pressure
levels. The results of this study demonstrated that these hypotensive
circulatory effects of marijuana are resolved with cessation of the drug,
meaning that a patient who uses marijuana could suffer from low blood
pressure during the time of use, which then resolves after stopping the drug.
The research about marijuana use contributing to changes in blood pressure
has led to mixed results, with some studies stating that medical marijuana
causes low blood pressure, while other results have demonstrated that
routine use causes an increase in blood pressure. Still other reports have
shown increases in diastolic levels but not systolic levels after exposure to
THC.39 While there may have been differences, there is much research and
personal anecdotes by those who have used marijuana and who have
experienced some change in blood pressure levels. However, the direction of
the blood pressure change and the extent to which increases or decreases in
levels occur most likely varies between individuals.
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Some people complain of feeling dizzy when using marijuana. When
combined with hypotension, dizziness and lightheadedness may be
intensified with these people. Patients who have used pharmaceutical
marijuana, such as dronabinol, have experienced changes in blood pressure
levels and have suffered from feelings of dizziness, orthostatic hypotension,
and syncope upon standing when using the prescribed drug.38 These
symptoms could be related to a drop in diastolic blood pressure or they
could be related to changes in cerebral blood flow. If a patient has been
prescribed medical marijuana and is experiencing these symptoms, it is best
to check the drug’s effects on the patient’s blood pressure, determine the
severity of the patient’s symptoms and their impact on daily life, and
consider other options for treatment, if possible.
Ischemic Heart Disease
Ischemic heart disease describes a condition in which blood flow is affected
in circulation because of the narrowing of the lumens of the coronary
arteries, typically because of atherosclerosis. The heart, the body’s tissues,
and other vital organs do not receive as much oxygenated blood because the
blood vessels develop plaque, which narrows the interior lumen of the
vessel; ultimately, the blood vessels are smaller in diameter and blood flow
is slowed. If the lumen of a vessel becomes so small that blood cannot flow
through properly, the patient can develop ischemia, which occurs with lack
of blood flow to the tissues distal to the site of occlusion. Ischemic heart
disease can cause a patient to have a myocardial infarction, in which part of
the tissue of the heart becomes necrotic and stops working properly because
of lack of blood flow.
Ischemic heart disease is a common form of chronic illness in the U. S,
causing death and disability for thousands of Americans every year. It is the
59
leading cause of death in the U.S. The Centers for Disease Control and
Prevention report that over 370,000 people die every year due to coronary
heart disease.67 There are many factors that contribute to worsening of the
condition, including a sedentary lifestyle and poor dietary intake, but studies
have also shown that use of marijuana may also contribute to ischemic heart
disease as well. With this in mind, clinicians who consider medical marijuana
as a form of treatment must assess for a history of ischemic heart disease in
their patients because the condition is so prominent within the population.
The healthcare provider should only prescribe medical marijuana for a
patient known to have ischemic heart disease with careful consideration.
Cannabinoid receptors that are targeted by endocannabinoids or by THC in
marijuana are found throughout the body at various points, including within
the cardiovascular system. When a person uses medical marijuana, the THC
in the drug activates these cannabinoid receptors and can cause changes in
the integrity of the blood vessel walls, potentially worsening atherosclerosis,
if present.40 Cannabinoid receptors, most often CB2 receptors, are also often
found on cells of immune function, including macrophages and T cells.
Cannabinoids play an important role in the regulation of immune system
function; because chronic inflammation contributes to atherosclerosis,
cannabinoids are important for modifying the immune system in response to
this chronic inflammation.
Another contributing factor toward atherosclerosis development is damage
to the endothelial lining of the vessel. When damage occurs to the
endothelial layer of the blood vessel, there is a greater risk of clot and
plaque formation, which can contribute to narrowing of the vessel and
turbulent blood flow. A study in Clinical Cardiology by Rajesh, et al.,
demonstrated that stimulation of CB1 cannabinoid receptors in the
60
endothelial cells of coronary arteries contributed to endothelial cell injury,
which could further potentiate development of plaque formation.41
Furthermore, smoking marijuana has been associated with an increase in
episodes of angina among patients who have diagnosed ischemic heart
disease. The effects of marijuana cause changes in heart rate, cardiac
output, and in some cases, blood pressure, and it may be linked to
triggering development of acute coronary syndrome (ACS).40
Because of these potential effects, medical marijuana should be used
carefully in patients who have diagnosed heart disease. A person with preexisting ischemic heart disease should already be on a regimen to control
diet and lifestyle factors to prevent other complications, such as a heart
attack or stroke. Even the effects that marijuana has on blood pressure and
heart rate can cause enough of a concern for patients who may be
susceptible to cardiac complications with using cannabis.
When responding to questions related to patient concerns about marijuana
use and its cardiovascular effects, many cardiovascular physicians have
mixed views.42 Some believe that there is not enough evidence to state
definitively that marijuana use should be banned completely because of its
cardiovascular effects; others have real concerns about marijuana’s effects
on the cardiovascular system and are seeing more patients with cardiac
problems because of the rise of medical marijuana use. Marijuana may or
may not have the same detrimental effects on the body as smoking tobacco.
Despite the mixed opinions of clinicians regarding this type of drug use, it
remains clear that more research is needed to discover the long-term effects
of medical marijuana use on the cardiovascular system.
61
Pregnancy
As with other drugs and medications, marijuana use during pregnancy
continues to be studied for its effects on both the mother and the developing
fetus. While many pregnant mothers are aware of the risks associated with
substance use, there are still thousands of pregnant women who use
marijuana, whether for recreation or for medicinal purposes. The full effects
of this practice remain to be seen for the mothers involved and their
children.
Marijuana use has not been shown to affect the physical outcomes of
pregnancy in terms of development of complications during pregnancy or
during labor and delivery. Women who use cannabis during pregnancy are
not at higher risk of complications such as pre-term labor, placental
insufficiency, or fetal growth retardation.29 Alternatively, marijuana has been
shown to cause problems with fetal brain development, ultimately causing
issues with the child’s learning methods and behaviors. This is referred to as
disturbances in a child’s executive functioning, which means that if a mother
uses cannabis during pregnancy, the child is at higher risk of later problems
with executive functioning, including decision-making, focus and
concentration, and recognizing cause and effect.
The chemicals in marijuana can cross the placental barrier and elevated
serum levels of marijuana have been found in the cord blood of infants of
mothers who use the drug. Newborn infants of mothers who use marijuana
may have positive urine tests of the drug. Marijuana may also be present in
meconium stool of newborn infants of mothers who use the drug, which
indicates use during the second and third trimesters, as these are the
months when stool forms in the fetal digestive tract. Based on these facts, it
is clear that when a pregnant mother uses marijuana, at least some of the
62
drug crosses the placental barrier to affect the infant. Marijuana may also be
found in breast milk, although to a much smaller extent when compared to
in utero exposure. A breastfeeding mother who uses marijuana may excrete
cannabis because it binds to the proteins in breast milk with recent use of
the drug.30
Cannabinoid receptors are found throughout the human body, including
within uterine tissue. With ingestion of marijuana, the fetus is exposed to
the drug when THC binds to these receptors. Regular exposure to THC in
marijuana and binding of these receptors places the growing fetus at risk of
deleterious effects on physical growth and development of synaptic nerve
responses in the brain that promote plasticity.31 The effects of cannabis on
neurotransmitters in the brain may further perpetuate problems in the
growing fetus and later in the developing child with growth and maturation
of the brain, impacting cognitive function, moods, and behavior.
Data from 2 longitudinal studies, the Ottawa Prenatal Prospective Study
(OPPS) and the Maternal Health Practice and Child Development Study
(MHPCD), reported in Clinical Perinatology, showed that children exposed to
marijuana before birth were more likely to demonstrate problems with
memory and language, decreased attentiveness, increased impulsivity, poor
visual problem solving, and increased hyperactivity when measured in
children between 3 and 10 years of age.31 Despite these results, overall
evidence about the exact effects of marijuana use during pregnancy is
inconclusive, as there are also many studies that have reported no adverse
fetal effects or negative childhood effects with marijuana use during
pregnancy. Regardless of the differences in study outcomes, medical
marijuana use remains an important factor to consider during pregnancy and
63
should be closely monitored if used at all, as with any other substance or
medication used during this time.
Because of the rising use of medical marijuana and its growing acceptance
as a valid form of medical treatment, more women who are pregnant are
using the drug. Some patients may compare marijuana to other harmful
substances used during pregnancy, such as tobacco or alcohol, and reason
that medical marijuana is not as harmful and is considered relatively safe
when compared to the effects of these substances and other illicit drugs.
Unfortunately, the public opinion of marijuana use is not necessarily backed
by truth about what can happen to the mother or her baby with regular
marijuana use during pregnancy.
Marijuana use during pregnancy also can impact the health of the mother
over time. Women with higher estrogen levels are more likely to be sensitive
to the effects of cannabis.28 Because a pregnant woman typically has greater
amounts of estrogen in her body during pregnancy, she may be more
susceptible to the effects of marijuana. Long-term exposure to medical
cannabis has also been shown to cause a drop in levels of certain hormones,
including luteinizing hormone, follicle stimulating hormone, prolactin, and
growth hormone; a pregnant woman who uses marijuana for a long period
of time may have more difficulties maintaining a healthy pregnancy.
Despite the fact that recreational use of marijuana has only been legalized in
two states and medical marijuana is not legal in all states, there are
significant numbers of pregnant women who use cannabis on a regular
basis. Individuals who regularly use marijuana have been shown to
demonstrate a decreased cognitive ability and problems with decisionmaking, which are characteristics of the acute effects of marijuana use.
64
However, with heavy use, these effects may last for several weeks or
months after stopping.30 A pregnant mother who uses marijuana,
particularly with heavy use, may still demonstrate changes in cognition that
can last further into her pregnancy, even if she stops using marijuana at
some point.
A woman who is pregnant and who uses marijuana for recreational purposes
could face criminal charges of child abuse if the situation is reported by a
healthcare provider, depending on the patient’s state of residence.30 Because
recreational use of marijuana during pregnancy is associated with problems
for both the mother and the child, medicinal use of marijuana during this
period should be recognized for its potential effects on the patient as well,
requiring strong and careful consideration before prescribing the drug.
Although it is not always performed, healthcare providers who make
recommendations for patients to use medical marijuana should consider
performing a pregnancy test on any patient who could be pregnant before
making the recommendation. Because medical marijuana has been shown to
be helpful in controlling nausea and vomiting, pregnant women may be more
likely to seek the comfort it can provide by controlling these symptoms as
well as other discomforts of pregnancy. However, prescribing and dispensing
medical marijuana to pregnant women can be dangerous and harmful to
both the mother and the child, which means that providers must consider
the effects of marijuana and weigh the benefits against the disadvantages
when it comes to these special situations.
History of Psychosis
Marijuana consists of a multitude of chemical compounds, including the
various cannabinoids present that cause many of the psychoactive effects
65
experienced by the user. Some patients with a history of mental illness
should not use medical marijuana because of its psychoactive effects. The
use of marijuana in some people who suffer from mental illness has been
shown to cause an increase in psychotic episodes, particularly when the drug
is used on a frequent basis.
The body already produces a certain amount of cannabinoids internally,
which are referred to as endogenous or endocannabinoids and which differ
from those taken in through cannabis ingestion. These endocannabinoids
bind to receptor sites throughout the body. This internal system of
endocannabinoids contains two types of receptors; some are more
prominent in the brain, while others are found in various areas, including on
some of the immune cells. Those receptors found in the brain are in
concentrated areas in such regions as the hippocampus, the prefrontal
cortex, the basal ganglia, and the cerebellum. The elevated areas of these
receptors are associated with the supposed neural system related to
cognitive function and psychosis.23
Endocannabinoids have similar actions as neurotransmitters in the brain in
that they regulate certain sensations, such as pain, mood, appetite, and
memory. However, unlike neurotransmitters, they also have the ability to
travel backward across nerve synapses and activate cannabinoid receptor
sites in previous pathways. This action can potentially affect the body’s
ability to regulate and release neurotransmitters.23 When a person ingests
marijuana, THC stimulates the cannabinoid receptor sites, also impacting
neurotransmitter release and causing overstimulation of the cannabinoid
receptors. This could be related to the psychotic effects that occur with the
drug’s use. Patients who have used marijuana for medicinal purposes have
claimed that it causes feelings of anxiety, being overwhelmed, a sense of
66
panic, or being paranoid.8 Because of the variations in the amount of
cannabinoids present in different preparations of marijuana, a patient who
uses medical marijuana could take in different amounts with each dose,
leading to different psychoactive effects with each use. Some forms of
marijuana, such as hashish, are much more concentrated and may contain
more cannabinoids in smaller amounts, resulting in potentially significant
mind-altering effects.
According to Lynch, et al., in the Psychiatric Times, up to 25 percent of
patients with schizophrenia suffer from comorbid cannabis use disorder.23
There is also an increased risk of developing psychosis later in life when
cannabis use occurs at a younger age. Marijuana’s association with
psychosis can worsen conditions such as schizophrenia in which the patient
suffers from psychotic episodes. It can be difficult to establish an exact
cause of psychotic episodes when multiple factors are present, including use
of marijuana. For instance, a person experiencing psychotic episodes may
have several factors present that increase risk of psychosis, including
marijuana use, a genetic vulnerability to mental illness, and a diagnosed
condition of another mental illness such as depression or severe anxiety.
Symptoms of schizophrenia, in particular, have been linked with worsening
manifestations of the condition when cannabis is used. Individuals with
schizophrenia who use marijuana have been shown to have increased
periods of psychotic symptoms, rates of relapse, probability of being
hospitalized, and, decreased response to anti-psychotic medications when
compared to those who do not use marijuana.33
There is enough evidence that demonstrates the use of medical marijuana
may worsen symptoms of mental illness that cause psychotic episodes, but
67
there is not enough information available to determine if using marijuana
will trigger a psychotic episode in a patient with a previously undiagnosed
condition. Because of this, prescribing healthcare providers should consider
and assess for whether the patient has a pre-existing condition that causes
periods of psychosis, such as schizophrenia, before recommending medical
marijuana as a form of treatment.
Medical Marijuana As A Methadone Withdrawal Treatment
Drug addiction is an illness that can be very difficult to treat; drug addiction
develops not only from the choices of the patient to use certain substances
inappropriately, but also from environmental and genetic factors that
contribute to the substance use disorder and addiction that develops. Drug
treatment programs and rehabilitation facilities are typically comprehensive
in their approach to helping patients manage and overcome a substance use
disorder because addiction to a drug affects so many aspects of an
individual’s life.
When providing treatment of methadone withdrawal, there are many factors
that must be considered. Treatment and inpatient rehabilitation will not work
for everyone. There will be some patients who do not respond to standard
forms of therapy or who need modifications in their treatment in order to be
successful. Relapse rates are often high and many people who undergo
detoxification and rehabilitation end up going through more than one
treatment cycle. The treatment provider must recognize the complexities
involved in drug treatment in order to provide a successful program.
Furthermore, any drug treatment program must focus on more than the
addiction; instead, it should be comprehensive enough that it considers and
manages the various factors affected by the patient’s drug use, including
68
emotional health, relationships with others, and vocational or educational
needs.
For some patients going through opiate withdrawal, such as with methadone
addiction, marijuana may be an option for alleviating some of the symptoms.
A study in the American Journal of Addictions showed that patients who used
marijuana while undergoing opiate withdrawal suffered less severe
symptoms of withdrawal.43 Methadone withdrawal symptoms can be
particularly uncomfortable for a patient who has developed an addiction to
the drug. Many people experience such symptoms as muscle aches, back
pain, restless legs, nausea and vomiting, and tremors. Use of cannabis
during this time may help to relieve some of the physical symptoms that
occur during the initial period of withdrawal.
Since cannabis has been used effectively to treat other medical conditions,
including those that cause pain, nausea, and vomiting, it is expected that
the drug would also be effective in managing symptoms of methadone
withdrawal. Some experts have argued that using marijuana for treatment
of opioid addiction is simply substituting one drug for another; however,
marijuana and opioids such as methadone do not affect the body in a similar
manner, and the extent to which a person becomes addicted to narcotics is
not the same as developing a marijuana substance use disorder. A news
release in the JAMA Network showed that states that have passed laws for
use of medical marijuana have lower death rates from opioid overdose when
compared to those states that do not legally allow medical marijuana.44
Further studies have shown that those who use cannabis as part of the
withdrawal process either decrease or eliminate their cannabis use when
withdrawal is complete.45
69
As with any type of recovery program that deals with a substance use
disorder and addiction, medical marijuana will not work for everyone, nor is
it an appropriate treatment for everyone. However, because of studies
associated with its use, it has been shown to be an effective form of
symptom management. Persons who have used marijuana as part of
methadone addiction treatment have stated that marijuana has helped to
provide a calming feeling while undergoing the uncomfortable symptoms and
that many of their physical symptoms were lessened, although not entirely
resolved. It may be that the THC found in medical marijuana has the same
positive effects on the physical withdrawal symptoms of methadone
addiction as it does when it is used for the treatment of other medical
conditions, such as with pain or inflammation.
For those who are proponents of medical marijuana use, its value in
managing withdrawal symptoms is yet another reason to consider
legalization of marijuana. If it can be used as part of the rehabilitation
process, many patients who are recovering from methadone addiction could
successfully make the transition to overcome their substance use and
addictions and go on to live drug-free lives.
Summary
Marijuana and methadone use are both controversial subjects in the medical
community. Methadone, while having been shown to be successful in helping
people to overcome opioid addictions, is still a topic of debate in some circles
as to its measure of success when used during detoxification. Some experts
believe that its use during withdrawal is simply substituting one drug for
another, and that people are at greater risk of becoming addicted to
methadone instead of being helped by it. Alternatively, thousands of people
70
have benefited from methadone use during drug withdrawal and are living
drug free because of it.
Marijuana also remains controversial, despite approved pharmaceutical
preparations and legislation approving its use for medicinal purposes.
Further research and long-term study is needed to determine whether
marijuana is helpful for those overcoming methadone addiction and to
determine the benefits and disadvantages of this method. Still, there are
many patients who have overcome their addictions by using marijuana to
combat uncomfortable symptoms. The process of substituting one drug for
another during the rehabilitation process is an option that is controversial,
but that also seems to work for many.
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
71
1. Use of cannabis may be able to help patients who struggle with
addiction to the synthetic opioid ________________.
a. heroin
b. methadone
c. oxycodone
d. morphine
2. True or False: Methadone prescriptions can be filled at any
licensed pharmacy ONLY if the drug is being used for pain relief and
is not being prescribed for addiction withdrawal.
a. True
b. False
3. Methadone may be used as an analgesic medication because
a. of methadone’s use in detoxification.
b. methadone helps patients experience fewer side effects of withdrawal.
c. methadone is a powerful pain reliever.
d. methadone manages the effects of withdrawal from some very strong
narcotics.
4. Some studies have determined that marijuana use may
a. cause problems with fetal brain development.
b. lower or raise blood pressure.
c. contribute to ischemic heart disease.
d. All of the above.
72
5. A patient who has asthma or breathing problems (i.e., chronic
lung disease) –
a. may take methadone but only intravenously.
b. may take methadone safely.
c. should not take methadone at all.
d. may take methadone so long as there are no other side effects.
6. True or False: Methadone use can also affect a patient’s ability to
breathe while sleeping, which can be particularly dangerous if the
patient takes the drug before going to bed.
a. True
b. False
7. Marijuana can be useful for patients receiving chemotherapy for
cancer because
a. marijuana gives the patient a better, overall sense of well-being.
b. marijuana has been shown to be effective in controlling nausea.
c. the body does NOT produce cannabinoids that could help cancer
patients.
d. marijuana helps control inflammation.
8. In a State where medicinal marijuana is legal, if a patient can
benefit from medical marijuana,
a. a physician may write a prescription for medicinal marijuana use.
b. a physician may recommend marijuana use but only if the drug is a
marijuana-based pharmaceutical.
c. then the use of marijuana would be legal under federal law as well.
d. a physician can make a recommendation for its use as part of
treatment.
73
9. The most common method for the administration of methadone is
______________.
a. pill form
b. intravenous injection
c. suppository form
d. liquid form
10. For some patients with methadone addiction, marijuana may be
an option for alleviating some of the withdrawal symptoms because
a. the patient is substituting one drug (marijuana) for another drug
(methadone).
b. of marijuana’s recreational nature.
c. marijuana is effective in controlling nausea and improving appetite.
d. marijuana and methadone affect the body in a similar manner.
11. Hashish is a form of concentrated
a. *marijuana.
b. cocaine.
c. methadone.
d. Heroine.
12. Hash oil can be
a. injected in its purest form.
b. *smoked or inhaled.
c. smoked only.
d. both a and b above.
74
13. Idrasil contains components of marijuana plant extract available
as
a. 50 mg syrup.
b. inhalant only.
c. *25 mg tablet.
d. 75 mg tablet.
14. Opioids such as methadone can cause _________________.
a. anorexia
b. *constipation
c. atrial fibrillation
d. None of the above.
15. True or False. Pharmaceuticals differ from neutraceuticals in that
neutraceuticals typically contain other combinations of drugs and
are not considered entirely natural.
a. True.
b. *False.
16. A patient taking methadone may develop symptoms of
a. slow or shallow breathing.
b. fatigue and sleepiness.
c. confusion.
d. *All of the above.
17. True or False. Methadone use can cause slow or irregular
breathing during sleep, or even periods of apnea.
a. *True.
b. False.
75
18. Methadone has a half-life of between _____________ hours in
the body.
a. 15 and 30 hours.
b. 25 and 50 hours.
c. *15 and 60 hours.
d. 30 and 60 hours.
19. Salpeter, et al., in the Journal of Palliative Medicine
demonstrated that low doses of methadone combined with
haloperidol provided
a. control of delusional episodes.
b. *exceptional pain relief for chronic pain.
c. prevention of psychosis related to comorbid pain.
d. prevention of sleep related disorders related to pain.
20. Methadone tablets are typically administered starting between
a. 2 mg and 5 mg every 6 hours.
b. 5 mg and 10 mg every 8 hours.
c. *2.5 mg and 10 mg every 8 hours.
d. 10 mg and 15 mg every 8 hours.
21. Sativex® is a sublingual spray used for the management of
a. anxiety and panic disorder.
b. major depression.
c. *spasticity associated with multiple sclerosis.
d. major depression and anxiety disorder.
76
22. Nabilone is available as an oral tablet usually taken
a. for major anxiety disorder
b. prior to starting chemotherapy for nausea and vomiting.
c. after chemotherapy is completed.
d. *Answers b and c above.
23. Blood vessels in the mouth andunder the tongue readily absorb
cannabinoids and types of sublingual products may be delivered as
a. lozenges.
b. sublingual spray.
c. medicated strips.
d. *All of the above.
24. High doses of methadone have been shown to cause
a. shortened Q-T intervals.
b. *dysrhythmia torsades de pointes.
c. cardiac issues in men more than women
d. complications in patients pre-existing kidney disease.
25. True or False. Patients taking too much methadone can
eventually develop pulmonary edema and be at risk of death from
respiratory failure.
a. *True.
b. False.
77
26. Heroin users with criminal histories have been shown to
decrease their level of involvement in crime during a 12-month
period when
a. prescribed mood stabilizers
b. *undergoing heroin addiction treatment.
c. undergoing behavioral therapy alone, such as CBT.
d. they expresseed readiness to stop using.
27. People have been harvesting marijuana for use for physical
ailments for hundreds of years. Initial legislation known was
a. *the Marihuana Tax Act of 1937
b. the Controlled Substances Act of 1970.
c. when dronabinol (Marinol®) was approved for cancer.
d. None of the above.
28. Regular ___________ testing may be required to check for the
presence of other drugs in the patient’s system when receiving
prescribed methadone.
a. Blood
b. *Urine
c. Breath
d. Both a and c above.
78
29. Journal of Clinical Sleep Medicine discussed the effects of opioid
use on breathing and sleep and endorsed all of the following
EXCEPT:
a. patients who take methadone and other opioid medications are at
higher risk of developing central sleep apnea.
b. central sleep apnea develops when there is interference when the
brain sends signals to the body to continue breathing while asleep.
c. *When eliminating opioid therapy in a patient with central sleep
apnea, the patient no longer experienced periods of apnea while
sleeping.
d. A drug such as methadone can increase the risk of central sleep
apnea.
30. Mothers that use marijuana have been found to
a. newborn infants with negative meconium stools.
b. *have newborn infants with positive urine tests of the drug.
c. show no marijuana found in breast milk.
d. show no effect to the fetus or newborn child.
31. Initial detoxification involves getting the patient through original
opioid excretion while taking methadone, and may include
a. reporting the patient to legal authorities for illegal use.
b. planning counseling and group therapy after the initial
detoxification process.
c. Assisting patients to manage their emotions and thoughts.
d. *Answers b and c above.
79
32. The most common use of methadone in withdrawal treatment is
for heroin addiction, however, it is also used for recovery from
a. severe cannabis addiction.
b. severe alcohol addiction.
c. *morphine and oxycodone addiction.
d. All of the above.
33. True or False. Methadone is administered to act as a substitute
for heroin because heroin is a long-acting drug.
a. True.
b. *False.
34. Methadone is a _________________ agent that can be used
once a day to prevent heroin cravings from developing for a person
with a heroin addiction.
a. long-acting.
b. short-acting.
c. treatment.
d. *Both a and c above.
35. Used illicitly, methadone is injected intravenously often by
injecting the liquid form of the medication that is prescribed for oral
use. This is extremely dangerous and can lead to
a. methadone toxicity/overdose.
b. infection with hepatitis B or HIV.
c. death.
d. *All of the above.
80
36. Methadone has a ______________ onset as compared to some
other opioid medications.
a. *slow.
b. rapid.
c. similar.
d. unpredictable.
37. True or False. When the patient uses heroin, the effects of the
drug develop quickly and he or she experiences a rapid rush of
euphoria.
a. *True.
b. False.
38. Topical applications of medical marijuana are available for the
treatment of some skin conditions and pain, and are available as
a. creams/lotions.
b. bath salts.
c. transdermal patches.
d. *All of the above.
39. True or False. Methadone is only available as oral, liquid or
injection forms (in the palliative setting).
a. True.
b. *False.
40. The recommended starting dose of methadone is
a. 1.5 mg every 8 hours.
b. *2.5 mg every 8 hours.
c. 5 mg every 8 hours.
d. 7.5 mg every 8 hours.
81
Correct Answers:
1.
b
11. a
21. c
31. d
2.
a
12. b
22. d
32. c
3.
c
13. c
23. d
33. b
4.
d
14. b
24. b
34. d
5.
c
15. b
25. a
35. d
6.
a
16. d
26. b
36. a
7.
b
17. a
27. a
37. a
8.
d
18. c
28. b
38. d
9.
d
19. b
29. c
39. b
10. c
20. c
30. b
40. b
References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
1.
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American Cannabis Nurses Association. Retrieved from
http://americancannabisnursesassociation.org/Resources/Documents/Nu
rsing-Practice/Nursing-PracticeGuidelines/safe%20cultivation%20and%20use%20website%20version.p
df
2.
Hospice and Palliative Nurses Association (HPNA). (2014). The Use of
Medical Marijuana (Position Statement). Pittsburgh, PA: HPNA
82
3.
National Conference of State Legislatures. (2015, Jun.). State medical
marijuana laws. Retrieved from
http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx
4.
United Patients Group. (2015). A beginner’s guide to using medical
marijuana. Retrieved from
http://www.unitedpatientsgroup.com/resources/beginners-guide
5.
National Institute on Drug Abuse. (2015, Apr.). Drug facts: Is marijuana
medicine? Retrieved from
http://www.drugabuse.gov/publications/drugfacts/marijuana-medicine
6.
Americans for Safe Access. (2015). Guide to using medical cannabis.
Retrieved from http://www.safeaccessnow.org/using_medical_cannabis
7.
Berkeley Patient’s Care Collective (PCC). (n.d.). Beginner’s guide to
medical cannabis—Using edibles. Retrieved from
http://berkeleypatientscare.com/2011/05/18/beginners-guide-tomedical-cannabis-using-edibles/
8.
Martin, M., Rosenthal, E., Carter, G. (2011). Medical marijuana 101.
Oakland, CA: Quick American Publishing
9.
Ghose, T. (2014, Jun.). NY legalizes medical marijuana: How vaping pot
is different from smoking. Live Science. Retrieved from
http://www.livescience.com/46536-vaporizing-marijuana-benefitsrisks.html
10. Sircus, M. (2011). Marijuana cannabinoids—Oral and transdermal
methods. Retrieved from
http://www.naturalnews.com/034425_marijuana_cannabinoids_medicin
e.html#
11. Narconon International. (2015). Signs and symptoms of methadone
abuse. Retrieved from http://www.narconon.org/drug-abuse/signssymptoms-methadone-use.html
83
12. Center for Substance Abuse Research (CESAR). (2013, Oct.).
Methadone. Retrieved from
http://www.cesar.umd.edu/cesar/drugs/methadone.asp
13. Demaret, I., Deblire, C., Litran, G., Magoga, C., Quertemont, E3,
Ansseau, M., Lemaitre, A. (2015). Reduction in acquisitive crime during
a heroin-assisted treatment: A post-hoc study. J Addict Res Ther 6(1).
Retrieved from http://omicsonline.org/open-access/reduction-inacquisitive-crime-during-a-heroinassisted-treatment-a-posthoc-study2155-6105-1000208.pdf
14. Drug Enforcement Administration (DEA). (2014, Mar.). Methadone.
Retrieved from
http://www.deadiversion.usdoj.gov/drug_chem_info/methadone/methad
one.pdf
15. Krueger, C. (2012, Mar.). Methadone for pain management. Practical
Pain Management. Retrieved from
http://www.practicalpainmanagement.com/treatments/pharmacological/
opioids/methadone-pain-management
16. Salpeter, S., Buckley, J., Bruera, E. (2013, Jun.). The use of very-lowdose methadone for palliative pain control and the prevention of opioid
hyperalgesia. J Palliat Med 16(6): 616-622.
17. MPR. (2014, Mar.). AAPM: Methadone not first drug of choice for chronic
pain. Retrieved from http://www.empr.com/news/aapm-methadonenot-first-drug-of-choice-for-chronic-pain/article/337276/
18. Ferrell, B., Coyle, N., Paice, J. (Eds.). (2015). Oxford textbook of
palliative nursing (4th ed.). New York, NY: Oxford University Press
19. Medline Plus. (2014, Aug.). Intestinal obstruction. Retrieved from
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84
20. Herndon, C., Jackson II, K., Hallin, P. (2002). Pathophysiology of opioidinduced constipation. Pharmacotherapy 22(2). Retrieved from
http://www.medscape.com/viewarticle/427442_4
21. C.A.R.E.S. Alliance. (2012). Methadone FAQ for healthcare professionals.
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